As promised below, I am sharing some of the responses I received from members of the staff and also outside observers after we announced our new goals for patient satisfaction and quality and safety. As you will see, there is a variety of opinion on the issue. This is not expected. I am going to divide them up by doctors, nurses and other staff, and outside folks who read the story or editorial in the newspaper or heard a radio interview.
I am not including my replies to these emails. You can offer your own replies in the comments!
Doctors
#1 -- How does BIDMC plan to determine if harm prevention measures are actually causing unintended harm? This isn't an idle question - we have bypassed much of the usual science of medicine when invoking quality improvement. We assume that if we force providers to don gloves and gowns before examining patients in an ICU that they will still go into the rooms just as much. We assume that the pass-off errors caused by resident work-hour changes won't exceed the benefits from reduced fatigue errors. We assume that the benefit of infections prevented by forms and checklists with central venous catheters makes up for the occasional delay in acute resuscitation. We assume that the benefits of medication reconciliation in the outpatient world will exceed the harm done by the loss of precious minutes spent actually talking with patients (my department can't even provide projected numbers on how long it should take the average MD to type in an average med list for our patients.) These are all measurable questions. Perhaps we assume too much? Auerbach's editorial on the question in the NEJM should have been a clarion call for us to redouble our efforts to evaluate change before declaring it beneficial.
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#2 -- I am delighted to hear from your email of the Hospitals' re-affirmation to emphasizing patient satisfaction.
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#3 -- (A) Makes me proud. I think that this is in part an ethics issue: there are few moral responsibilities we have as serious and widely acknowledged as the Hipprocratic admonition to “Do No Harm.”
(B) At our monthly Ethics Rounds (held in every ICU and 15-20 units total) we should consider moving from asking about “any cases of adverse events in the past month that you think weren’t disclosed/reported properly?” to “any cases in the past month where a patient was harmed by something we did that was preventable?”
(C) We could also encourage our individual Ethics Liaisons (designated by the chiefs of more than 50 clinical and administrative units) to think about ways they can help foster a culture in which we take moral responsibility for not harming patients, and constructive “preventive ethics” efforts not to do so in the future.
We have found our many Ethics Rounds a useful tool in the past for exploring in a BIDMC-wide way the views or experiences of front-line clinical staff about ethical aspects of issues such as a possible VIP unit. Our Ethics Liaisons Program is already proving it has great potential for engaging a large group of individuals across multiple departments.
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#4 -- (Reply comment from another doctor:) RE "C", I would emphasize even more strongly that the moral responsibility is to learn as much as possible from every episode of harm in order to prevent that harm from recurring. We need to remain clear that competent and well intentioned providers may find themselves part of an event in which there is harm, and foster the culture where people see these as learning opportunities to prevent future harm.
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#5 -- This is good, and it is clear that goal number one can be published because it only provides a measuring stick (new for BIDMC) for something we have already been doing. But goal number two: How does the hospital elegantly air this goal without the fear of being criticized for not having been doing this all along? Perhaps a better wording would be to emulate the wording of the first goal and say that we will establish new measures to ensure that our preventive measures work, so that we can fix them if they don't.
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#6 -- I really liked your very thoughtful and important words on public radio this morning.
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# 7 -- I am concerned about the wording of the second goal- there is a problem when you set an unobtainable goal, only to publicly show that you couldn't achieve it. Here is the unobtainable goal:
"BIDMC will eliminate all preventable harm by January 1, 2012."
This cannot be done, because it is stated in absolute terms. Eliminating "all preventable harm" is a noble ideal, but it is unrealistic given the complexity of delivering health care by multiple layers of teams and individuals. The best that any hospital can do is to develop mechanisms to reduce preventable harm, not to guarantee that all harm will be prevented. Any preventable harm, even if it was humanly impossible to foresee it, and even if no other hospital could prevent it, will be held against us as a failure to achieve what we promised.
I suggest that this second goal be revised as follows:
BIDMC will continue to create an environment that reduces preventable harm to the fullest extent possible. To this end, by January 1, 2012 we will be recognized as a national leader in the field of patient safety. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.
This is also a noble goal, but it has the merit of being achievable....
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#8 -- This is great, and the report in yesterday’s Globe has a lot of people elsewhere talking about it, and very favorably. May I suggest that the next step, given your interest and ability to be well ahead of the curve, would be – where the specific data permits such granularity – to know and report whether results were similar or different segmented by race, ethnicity, age group and gender. It would be fabulous to be able to say, with respect to various indices of care, that there was no difference at BIDMC when examined by race, ethnicity, gender and age group.
Nurses and other staff
#1 -- I treasure my place here and I imagine it will be a very long time before I will look elsewhere. I love this safety and quality initiative and I even love the naming exercise for the "thing"!!! Thanks for being who you are- it makes it possible for us to be who we are as well.
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#2 -- Thank you for taking the lead in making and returning BIDMC a wonderful place for patients. I hope to contribute to the attainment of this goal as a clinical nurse.
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#3 -- I am a nurse working at [a specified floor], and was just wondering if this meeting was in response to latest news that medical insurance will not be reimbursing hospitals for preventable occurrences (aside from the obvious that we care and value patient safety and prove that we are one if not the BEST hospital in Boston)?
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#4 -- Take the leaps...set the goals...Count Me In!
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#5 -- These are goals we can certainly reach. Over the last two years, we've made great strides creating performance measures in the Department of Medicine's divisions. After many meetings with our colleagues and data collection, it feels good to see the improvements based on our results.
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#6 -- You have my support...please let me know what I can do to attain the goals you have set.
This is an awesome hospital....and I'd like to help make the patient experience even better.
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#7 -- Although the initiatives you are describing relate to patient care, I believe that all subjects in research studies are patients as well. Please do not hesitate to contact me if I can lend my support and experience to any committees under development or in any way you see fit.
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#8 -- WOW!
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#9 -- These initiatives are terrific. I appreciate them both as an employee but more importantly, I appreciate it as a patient. Should I, or my family, be so sick that we need to be hospitalized, I want to feel confident, when we are most vulnerable, that we will be cared for safely. While we have not ever been hospitalized, we have utilized the outpatient services and have run up against some significant gaps in quality care. I've raised those issues with the appropriate managers and in both cases they responded quickly and appropriately. We have a way to go at all levels. You can count on me to help work toward these goals.
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#10 -- I appreciate your and the Board's "raising the bar" at BIDMC and BID-Needham. I am looking forward to doing my part.
I want to make sure you're aware of something I saw at the FDA website. I imagine you are aware of it but since it appears to be right in line with the announced aspirations and "The Thing" I felt I should take a chance at being redundant. The title of the FDA program is "AHRQ Releases Toolkits to Help Providers and Patients Implement Safer HealthCare Practices" and here is the link.
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#11 -- A thought about patient feedback: The several times I have been hospitalized, the efforts of staff to go beyond courtesy to make me feel taken care of and cared about have always stayed with me more than anything else about a hospital stay. And of course, apathy, lassitude or grumpiness has made an equally strong impression on me. There were times when I felt mistreated by “bad apples” (not at BIDMC). At the time, I wished I had had the opportunity to give feedback to the hospital. However, in the weakened state of illness, patients do not have the physical or mental energy to seek recourse on their own. If patients were given feedback cards (as often happens in restaurants) when they are admitted (not on leaving, when the memory is less accurate), this would help in more ways than one: the patient would feel he/she had recourse, and would thus leave feeling the hospital cared, even if the “bad apple” didn’t appear to, and 2) if they know patients have this forum, bad apples are likely to take more care how they treat patients.
Question regarding the phrase in your email: “We will measure ourselves based on national benchmarks”: I was just wondering if national benchmarks include a measure of staff satisfaction, since patient satisfaction depends daily on the way they are treated.
Outside folks
#1 -- I can say that after my experiences @ BI & my husband's experiences at an unnamed hospital, you are well ahead in the process & examples.
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#2 -- Bravo!
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#3 -- Bravo! I will follow with great interest.
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#4 -- Reading today's Globe, I was once again struck by how very proud I am to be associated with Beth Israel Deaconess Medical Center. Not only do I appreciate your forward thinking but am amazed at your goal to not only be first, but to do right.
Congratulations. This is a great day.
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#5 -- Congratulations to both of you and your Boards for this outstanding initiative.
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#6 -- Hearty congratulations and a bold and positive step!
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#7 -- First rate and I am sure will be supported by all of us.
One issue to think about over time. You can make the hospital experience great and are doing that. However, with the advent of out patient care and day surgery, much of the experience takes place in the doctor's office. Some are not so great at continuing the great feeling one gets at the hospital.
As a lawyer I represent many banks. I am acutely aware that how I treat the bank's customer in documenting the transaction reflects back at the bank.
I hope you can (or can continue to) foster that feeling in your doctors.
Regards and with continuing admiration for what you are doing.
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#8 -- Congratulations on your quality goals. Nice to see someone put a stake in the ground and focus on what this business is really about.
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#9 -- Impressive move by you and your board. That's the way to push the envelope. Let's hope others take up the challenge as well.
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#10 -- Great Globe Editorial today! I’m so proud to now be a BI patient!
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#11 -- Good luck with the initiative. It’s a big undertaking.
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#12 -- I am really delighted that you have chosen to meet this head on. Obtaining accurate data and putting the CARE back into healthcare will continue to keep us in the forefront both in Boston and nationally.
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#13 -- I can’t tell you how excited I am by your commitment to avoid all preventable harm to patients. It is simply the right thing to do. In a similar vein, I first learned of Ascension Health’s commitment to “no preventable deaths by 2008” in the fall of 2004. I have known Dr. Sandy Tolchin for many years and have had the opportunity to learn of his efforts, initially at Borgess Health Alliance in Kalamazoo and now as VP Clinical Excellence in collaboration with David Prior and others at Ascension Health. When I last spoke with him in the late fall, he said, “We have now demonstrated that flawless care is achievable.”
Monday, January 21, 2008
Saturday, January 19, 2008
What's in a PCAC?
Following on our theme below, I am presenting a bit more on our governance of hospital safety and quality to provide background to others in the field who might be interested. A friend asked me how our Patient Care Assessment and Quality Committee (PCAC) is constituted and what its charter is. Here it is in its entirety. The key points are that its job is related to the overall institutional goals established by the Board of Directors (the ones mentioned below), as well as statutory responsibilities. Also, that membership by the lay leadership (entitled "Medical Center Governance" below) always exceeds that of internal management and clinical leadership. Note, too, the inclusion of the Vice President of Education to ensure that quality and safety programs are integrated into the educational programs for both medical students and residents -- very important in an academic medical center.
This is a hard-working committee for the volunteer leadership, meeting monthly and dealing with difficult and challenging issues. We have great appreciation for those people, who devote hours well beyond the committee meetings in staying informed and thinking about the most important topics on the Board's agenda.
BIDMC Committee Charter
Patient Care Assessment and Quality Committee (PCAC)
Reports To: BIDMC Board of Directors
Mission:
The mission of the Patient Care Assessment and Quality Committee (PCAC) is to support the aspirations for clinical quality and safety for BIDMC as set forth by the Board of Directors, and make appropriate recommendations for improvement. The PCAC shall also serve the role of Medical Peer Review Committee as defined under the statutes of the Commonwealth of Massachusetts.
Charge and Scope:
Monitor the occurrence of harm to BIDMC patients, with a focus on response and corrective action when harm occurs.
Select and monitor priority metrics that evaluate clinical quality and safety processes and outcomes achieved within BIDMC.
Recommend to the Board of Directors, at least annually, priority initiatives for improving quality and safety of care at BIDMC, and monitor the extent to which approved priority initiatives are satisfactorily executed.
Ensure that BIDMC remains alert to current best practices for quality and safety, at BIDMC and other entities (in health care as well as other settings), and recommends appropriate adoption. This shall include ensuring that best practices within BIDMC itself are spread and implemented throughout the organization.
Approve annually the Qualified Patient Care Assessment Program.
Ensure that all regulatory reporting mandates for clinical performance, including the filing of major incident reports to the Commonwealth, are met.
Ensure that members of the Committee have the appropriate knowledge and training necessary to carry out the mission of the committee.
Committee Chair:
Member of BIDMC Governance, Appointed by Chair of Board of Directors
Members:
Chair (Member of Medical Center Governance)
Vice Chair (Member of Medical Center Governance)
Chair, Board of Directors, ex officio
CEO, ex officio
President, faculty practice, ex officio
Chair, Medical Executive Committee, ex officio
Chair, Deptartment of Surgery, ex officio
Chair, Department of Medicine, ex officio
Chair, Academic Department (Rotating 1 year appointment, appointed by the Chair of the Medical Executive Committee)
Vice President, Education, ex officio
11-24 Members (Members of Medical Center Governance)
Staff:
Chief Operating Officer
Senior Vice President, Clinical Operations
Senior Vice President, Health Care Quality
Patient Care Assessment Coordinator
Meeting Schedule:
Monthly (except no August meeting)
This is a hard-working committee for the volunteer leadership, meeting monthly and dealing with difficult and challenging issues. We have great appreciation for those people, who devote hours well beyond the committee meetings in staying informed and thinking about the most important topics on the Board's agenda.
BIDMC Committee Charter
Patient Care Assessment and Quality Committee (PCAC)
Reports To: BIDMC Board of Directors
Mission:
The mission of the Patient Care Assessment and Quality Committee (PCAC) is to support the aspirations for clinical quality and safety for BIDMC as set forth by the Board of Directors, and make appropriate recommendations for improvement. The PCAC shall also serve the role of Medical Peer Review Committee as defined under the statutes of the Commonwealth of Massachusetts.
Charge and Scope:
Monitor the occurrence of harm to BIDMC patients, with a focus on response and corrective action when harm occurs.
Select and monitor priority metrics that evaluate clinical quality and safety processes and outcomes achieved within BIDMC.
Recommend to the Board of Directors, at least annually, priority initiatives for improving quality and safety of care at BIDMC, and monitor the extent to which approved priority initiatives are satisfactorily executed.
Ensure that BIDMC remains alert to current best practices for quality and safety, at BIDMC and other entities (in health care as well as other settings), and recommends appropriate adoption. This shall include ensuring that best practices within BIDMC itself are spread and implemented throughout the organization.
Approve annually the Qualified Patient Care Assessment Program.
Ensure that all regulatory reporting mandates for clinical performance, including the filing of major incident reports to the Commonwealth, are met.
Ensure that members of the Committee have the appropriate knowledge and training necessary to carry out the mission of the committee.
Committee Chair:
Member of BIDMC Governance, Appointed by Chair of Board of Directors
Members:
Chair (Member of Medical Center Governance)
Vice Chair (Member of Medical Center Governance)
Chair, Board of Directors, ex officio
CEO, ex officio
President, faculty practice, ex officio
Chair, Medical Executive Committee, ex officio
Chair, Deptartment of Surgery, ex officio
Chair, Department of Medicine, ex officio
Chair, Academic Department (Rotating 1 year appointment, appointed by the Chair of the Medical Executive Committee)
Vice President, Education, ex officio
11-24 Members (Members of Medical Center Governance)
Staff:
Chief Operating Officer
Senior Vice President, Clinical Operations
Senior Vice President, Health Care Quality
Patient Care Assessment Coordinator
Meeting Schedule:
Monthly (except no August meeting)
Thursday, January 17, 2008
Source material on quality, safety, and patient satisfaction
As a follow-up to the post below on the quality, safety, and patient satisfaction goals established by the BIDMC and BID~Needham Boards, I thought some of you might be interested in reading the material that led to the votes. It is a bit long, but descriptive of the issues that were considered. For some of you, this might be more than you want to know. For others, it might provide primary source information that could be valuable for your own institutions. My hope is that more hospitals will find themselves moving in this direction, and if the accompanying memo helps in your own consideration, please feel free to use it. (In the memo below, the LEAD program refers to a partnership between our hospitals and Blue Cross Blue Shield of MA, under which auspices the Board training program was held.)
In my next posting, I plan to give you a sense of the internal feedback that I have received since making this announcement.
To: BIDMC Board of Directors and PCAC Members
BID-Needham Board of Trustees and PCAC Members
From: Lois E. Silverman, Chair, BIDMC Board of Directors
Seth Medalie, Chair, BID-Needham Board of Trustees
Robert Melzer, Chair, BIDMC PCAC
Paula Ivey Henry, Vice Chair, BIDMC PCAC
Christoph Hoffmann, Chair, BID-Needham PCAC
Paul F. Levy, CEO, BIDMC
Jeffrey H. Liebman, CEO, BID-Needham
Ken Sands, MD, Senior Vice President, Healthcare Quality
Stan Lewis, MD, Senior Vice President, Network Development
Dianne Anderson, Senior Vice President, Clinical Operations
Re: LEAD Board Program Follow-up
Date: November 30, 2007
Dear Board Members,
Following our immensely engaging LEAD retreat last month, a group of us got together to draft a proposal on quality and safety goals for both hospitals for your formal consideration.
It was clear from the retreat discussions that there should be two ambitious overarching goals for both institutions: One for the quality and safety of care and another for patient satisfaction.
The group agreed that the Board’s role is to set an expectation for organizational performance for these two areas. Management is then expected to devise programs for achieving these goals, and to determine the metrics against which performance will be measured. We anticipate that the structure of the Board meetings will change to include systematic reviews of the programs related to these goals on a quarterly basis.
On the patient satisfaction front, we propose the following goal:
BIDMC and BID-Needham will create a consistently excellent patient experience. We will measure ourselves based on national benchmarks and, by January 1, 2012, be in the top 2% of hospitals in the country, based on national survey responses to “willingness to recommend.” For this goal, BID-Needham will measure itself against national peer group hospitals and BIDMC against a national dataset of all hospitals.
A top 2% goal means that effectively nine out of every ten patients rate the hospital in the top tier category on national surveys for willingness to recommend. BIDMC is presently performing in the top 10-15% range, on average. BID-Needham is in the top 30%. This goal represents a steep climb in performance for both institutions.
Formulating a goal for quality and safety proved more challenging, as there is a broad spectrum of definitions for harm and error, and consequently a broad range of implications for goal setting. First, there is a distinction between preventable and non-preventable harm. The latter type occurs when a patient is harmed as a result of a cause that could not have been predicted or prevented, such as the administration of a drug resulting in an adverse reaction that a patient’s history would not have indicated. Preventable harm, on the other hand, occurs when there is a failure on the part of either an individual or a system to render ideal care, such as when the administration of an incorrect dose or medication results in an adverse outcome causing actual injury to the patient.
It should further be noted that there is a distinction between harm and error, and that not all errors result in harm to the patient. For example, an incorrect dose of a particular drug administered to a patient might not affect the patient. The Institute for Healthcare Improvement (IHI) reports that only 10 to 20% of errors are ever reported, and of those, 90 to 95% cause no harm to patients. While much can be learned from all errors, many (including IHI) recommend that institutional governance focus on those causing actual harm. The theory is that by discussing openly those events actually experienced by patients, a hospital begins to foster a culture of safety that shifts from individual blame for errors to comprehensive system design and therefore lasting improvement in safety.
The first step in identifying harm is to develop a clear definition. Our small group reviewed several definitions of harm, ranging from IHI’s very comprehensive definition of all harm, including preventable and non-preventable harm, to the Ascension Healthcare System’s quality goal of no preventable harm. We felt that we needed to focus our resources where we can have the greatest impact, on eliminating preventable harm. At the same time, we wanted to maintain an organizational awareness of all harm, including non-preventable adverse events, and to seek to reduce our overall incidence of harm. The goal that we propose for quality and safety, therefore, is:
BIDMC and BID-Needham will eliminate all preventable harm by January 1, 2012. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.
To determine and clarify how we would actually measure harm, we propose a modification of the categorization developed by the National Coordinating Council for Medication Error and Reporting and Prevention, known as the “NCC-MERP” Framework, to consist of the following categories of evidence of harm:
- Required hospitalization or extended hospitalization
- Permanent harm or disease progression
- Patient death
We feel that focusing on these categories will give us the greatest opportunity to achieve a meaningful and sustainable reduction in harm, while making the best use of our resources. The occurrence of harm that falls into any one of these categories would qualify for individual case review. In addition, while the boards of our institutions will focus on “preventable harm,” we also expect our respective PCAC committees to develop systems for periodic assessment and reporting on the occurrences of harm that are not within the categories listed above.
It is important for the Boards and the respective organizations to understand that these goals represent a far-reaching aspiration for our hospitals and for the level of care that we seek to provide. We must acknowledge that getting there will be a three to four year journey that will require further strengthening of our culture of safety and transparency. It will mean further bolstering our efforts to create an environment where caregivers feel safe discussing the occurrence of harm.
We discussed and propose the following timeline: At the December Board meetings, each Board will discuss and vote on these proposed goals and the attached resolution. Management would then be charged with outlining specific programs with measurable milestones to achieve these goals. In January, staff will be asked to present to their respective PCAC committee a timetable for these programs for the following year, along with a trajectory of performance towards the end goals. Upon review and approval by the respective PCAC committee, the action plans and milestones will be brought to the Board at its first subsequent meeting. A quarterly review of progress towards these goals would then become a regular element of each institution’s Board and PCAC meetings. In addition, the Compensation Committee of each hospital will be charged with building these quality and safety goals into the annual incentive plans for senior management.
We welcome your feedback and questions on these proposed goals, and look forward to our discussions at the December Board meetings.
In my next posting, I plan to give you a sense of the internal feedback that I have received since making this announcement.
To: BIDMC Board of Directors and PCAC Members
BID-Needham Board of Trustees and PCAC Members
From: Lois E. Silverman, Chair, BIDMC Board of Directors
Seth Medalie, Chair, BID-Needham Board of Trustees
Robert Melzer, Chair, BIDMC PCAC
Paula Ivey Henry, Vice Chair, BIDMC PCAC
Christoph Hoffmann, Chair, BID-Needham PCAC
Paul F. Levy, CEO, BIDMC
Jeffrey H. Liebman, CEO, BID-Needham
Ken Sands, MD, Senior Vice President, Healthcare Quality
Stan Lewis, MD, Senior Vice President, Network Development
Dianne Anderson, Senior Vice President, Clinical Operations
Re: LEAD Board Program Follow-up
Date: November 30, 2007
Dear Board Members,
Following our immensely engaging LEAD retreat last month, a group of us got together to draft a proposal on quality and safety goals for both hospitals for your formal consideration.
It was clear from the retreat discussions that there should be two ambitious overarching goals for both institutions: One for the quality and safety of care and another for patient satisfaction.
The group agreed that the Board’s role is to set an expectation for organizational performance for these two areas. Management is then expected to devise programs for achieving these goals, and to determine the metrics against which performance will be measured. We anticipate that the structure of the Board meetings will change to include systematic reviews of the programs related to these goals on a quarterly basis.
On the patient satisfaction front, we propose the following goal:
BIDMC and BID-Needham will create a consistently excellent patient experience. We will measure ourselves based on national benchmarks and, by January 1, 2012, be in the top 2% of hospitals in the country, based on national survey responses to “willingness to recommend.” For this goal, BID-Needham will measure itself against national peer group hospitals and BIDMC against a national dataset of all hospitals.
A top 2% goal means that effectively nine out of every ten patients rate the hospital in the top tier category on national surveys for willingness to recommend. BIDMC is presently performing in the top 10-15% range, on average. BID-Needham is in the top 30%. This goal represents a steep climb in performance for both institutions.
Formulating a goal for quality and safety proved more challenging, as there is a broad spectrum of definitions for harm and error, and consequently a broad range of implications for goal setting. First, there is a distinction between preventable and non-preventable harm. The latter type occurs when a patient is harmed as a result of a cause that could not have been predicted or prevented, such as the administration of a drug resulting in an adverse reaction that a patient’s history would not have indicated. Preventable harm, on the other hand, occurs when there is a failure on the part of either an individual or a system to render ideal care, such as when the administration of an incorrect dose or medication results in an adverse outcome causing actual injury to the patient.
It should further be noted that there is a distinction between harm and error, and that not all errors result in harm to the patient. For example, an incorrect dose of a particular drug administered to a patient might not affect the patient. The Institute for Healthcare Improvement (IHI) reports that only 10 to 20% of errors are ever reported, and of those, 90 to 95% cause no harm to patients. While much can be learned from all errors, many (including IHI) recommend that institutional governance focus on those causing actual harm. The theory is that by discussing openly those events actually experienced by patients, a hospital begins to foster a culture of safety that shifts from individual blame for errors to comprehensive system design and therefore lasting improvement in safety.
The first step in identifying harm is to develop a clear definition. Our small group reviewed several definitions of harm, ranging from IHI’s very comprehensive definition of all harm, including preventable and non-preventable harm, to the Ascension Healthcare System’s quality goal of no preventable harm. We felt that we needed to focus our resources where we can have the greatest impact, on eliminating preventable harm. At the same time, we wanted to maintain an organizational awareness of all harm, including non-preventable adverse events, and to seek to reduce our overall incidence of harm. The goal that we propose for quality and safety, therefore, is:
BIDMC and BID-Needham will eliminate all preventable harm by January 1, 2012. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.
To determine and clarify how we would actually measure harm, we propose a modification of the categorization developed by the National Coordinating Council for Medication Error and Reporting and Prevention, known as the “NCC-MERP” Framework, to consist of the following categories of evidence of harm:
- Required hospitalization or extended hospitalization
- Permanent harm or disease progression
- Patient death
We feel that focusing on these categories will give us the greatest opportunity to achieve a meaningful and sustainable reduction in harm, while making the best use of our resources. The occurrence of harm that falls into any one of these categories would qualify for individual case review. In addition, while the boards of our institutions will focus on “preventable harm,” we also expect our respective PCAC committees to develop systems for periodic assessment and reporting on the occurrences of harm that are not within the categories listed above.
It is important for the Boards and the respective organizations to understand that these goals represent a far-reaching aspiration for our hospitals and for the level of care that we seek to provide. We must acknowledge that getting there will be a three to four year journey that will require further strengthening of our culture of safety and transparency. It will mean further bolstering our efforts to create an environment where caregivers feel safe discussing the occurrence of harm.
We discussed and propose the following timeline: At the December Board meetings, each Board will discuss and vote on these proposed goals and the attached resolution. Management would then be charged with outlining specific programs with measurable milestones to achieve these goals. In January, staff will be asked to present to their respective PCAC committee a timetable for these programs for the following year, along with a trajectory of performance towards the end goals. Upon review and approval by the respective PCAC committee, the action plans and milestones will be brought to the Board at its first subsequent meeting. A quarterly review of progress towards these goals would then become a regular element of each institution’s Board and PCAC meetings. In addition, the Compensation Committee of each hospital will be charged with building these quality and safety goals into the annual incentive plans for senior management.
We welcome your feedback and questions on these proposed goals, and look forward to our discussions at the December Board meetings.
Aspirations for BIDMC and BID~Needham
Here is an email I sent last night to the staff of BIDMC and our community hospital, BID~Needham. Thanks to CEO Cleve Killingsworth and others at Blue Cross Blue Shield of MA for being our partners in the Board training and providing other assistance and encouragement that helped lead to this step: Please see Jeff Krasner's story and an editorial in today's Boston Globe. Special thanks to Jim Conway at the Institute for Healthcare Improvement for his wise counsel and for conducting a significant segment of our Boards' training, and to three unnamed patients who addressed the Boards and powerfully made these issues tangible. Finally, after the text of this email, please read the statement we received on this matter from State Senator Richard T. Moore (Senate Chair of the Joint Committee on Health Care Financing).
Dear BIDMC,
There are some things that we do that are meant to transform our hospital, to set us on a path to very high standards that, at first blush, appear so audacious as to be unachievable. But if you never take the leap and set out the goals, you never know what you really can achieve.
Today, we announce such goals, in the hope that they will set the stage for such a transformation.
Several weeks ago, the Board of Directors of BIDMC and the Board of Trustees of BID~Needham met and had serious discussions about what their hopes were for our two hospitals. As the representatives of the community who have fiduciary responsibility for our two non-profit organizations, they decided on a pair of goals that represent their aspirations for us. Of course, the clinical and administrative leadership of the hospital were deeply involved in these discussions as well and provided the technical support for the decisions that were made.
The Boards decided that two overarching types of goals were important. The first relates to patient satisfaction. The second relates to safety and quality of care. Here is the vote that was taken by the BIDMC Board (and a virtually identical one was taken by the BID~Needham Board):
WHEREAS, the Board of Directors, Patient Care Assessment and Quality Committee ("PCAC"), and Patient Care Services Committee ("PCS Committee") of Beth Israel Deaconess Medical Center ("BIDMC") have determined that it is in the best interest of BIDMC to set ambitious and overarching goals related to healthcare quality and patient safety, and patient satisfaction.
NOW THEREFORE BE IT RESOLVED AS FOLLOWS:
To approve the following goals for BIDMC related to healthcare quality and patient safety, and patient satisfaction:
BIDMC will create a consistently excellent patient experience. We will measure ourselves based on national benchmarks and, by January 1, 2012, be in the top 2% of hospitals in the country, based on national survey responses to "willingness to recommend." For this goal, BIDMC will measure itself against a national dataset of all hospitals.
BIDMC will eliminate all preventable harm by January 1, 2012. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.
That Management will develop and implement action plans and programs to achieve these goals, to be reviewed and approved by the PCAC Committee, PCS Committee, and the Board, and will report to the Board, PCAC, and PCS Committee on at least a quarterly basis using defined metrics against which performance will be measured.
Daunting, eh? You bet. Here's more. We will be publicizing our progress towards these goals on our external website for the world to see. In other words, we will be holding ourselves accountable to the public for our actions and deeds. Our steps towards transparency have just been notched up a level.
These Board votes certainly do not mean that we are not already doing a good job now. Our Boards have immense respect and affection for all of the staff who work in our hospitals. They know you take really good care of patients and provide a warm and caring environment for patients and families. But the votes mean that our Board members who represent the community want us to do even better, out of a sense of public service and also out of a sense of pride that we can do better.
Over the last several months, we have seen a hint of what is possible. Our efforts at infection control on the floors and in the ICUs are but a few examples. Meanwhile, too, we have made process and customer service improvements in a number of clinics. We have saved lives, reduced adverse events, improved customer satisfaction, and made life a bit less hectic for some of our staff. (You know from previous emails that I am working hard to make even more improvements on that latter point.)
We have come a long way. Six years ago, both of our hospitals were close to being sold or shuttered. Four years ago, we had passed through a turn-around and proved our ability to survive. These past two years, we have shown that we are vibrant members of the Boston and Harvard medical communities. Now, we rise to the largest challenge yet -- setting standards for patient satisfaction and reduction of harm that are truly world class.
Stay tuned as we roll this out and decide on the yearly priorities and work plans that will eventually lead to reaching these audacious goals. In the meantime, as always, please keep in touch with your ideas, suggestions, and criticisms.
Sincerely,
Paul
Here is Senator Moore's statement:
“BI-Deaconess deserves to be strongly commended for taking this challenging, bold step to improve health quality and transparency. By including a small community hospital (BID-Needham) as well as a major academic medical center, BI-Deaconess becomes a true champion of health care quality and patient safety. Their leadership in promoting transparency is unprecedented in the Commonwealth, and is fully consistent with the principles behind legislative initiatives such as Senate Bill No. 1277/House Bill No. 2226, An Act Improving Consumer Healthcare Quality. They obviously understand the meaning of 'First, Do No Harm.' They get it right!”
Thank you, Senator!
Dear BIDMC,
There are some things that we do that are meant to transform our hospital, to set us on a path to very high standards that, at first blush, appear so audacious as to be unachievable. But if you never take the leap and set out the goals, you never know what you really can achieve.
Today, we announce such goals, in the hope that they will set the stage for such a transformation.
Several weeks ago, the Board of Directors of BIDMC and the Board of Trustees of BID~Needham met and had serious discussions about what their hopes were for our two hospitals. As the representatives of the community who have fiduciary responsibility for our two non-profit organizations, they decided on a pair of goals that represent their aspirations for us. Of course, the clinical and administrative leadership of the hospital were deeply involved in these discussions as well and provided the technical support for the decisions that were made.
The Boards decided that two overarching types of goals were important. The first relates to patient satisfaction. The second relates to safety and quality of care. Here is the vote that was taken by the BIDMC Board (and a virtually identical one was taken by the BID~Needham Board):
WHEREAS, the Board of Directors, Patient Care Assessment and Quality Committee ("PCAC"), and Patient Care Services Committee ("PCS Committee") of Beth Israel Deaconess Medical Center ("BIDMC") have determined that it is in the best interest of BIDMC to set ambitious and overarching goals related to healthcare quality and patient safety, and patient satisfaction.
NOW THEREFORE BE IT RESOLVED AS FOLLOWS:
To approve the following goals for BIDMC related to healthcare quality and patient safety, and patient satisfaction:
BIDMC will create a consistently excellent patient experience. We will measure ourselves based on national benchmarks and, by January 1, 2012, be in the top 2% of hospitals in the country, based on national survey responses to "willingness to recommend." For this goal, BIDMC will measure itself against a national dataset of all hospitals.
BIDMC will eliminate all preventable harm by January 1, 2012. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.
That Management will develop and implement action plans and programs to achieve these goals, to be reviewed and approved by the PCAC Committee, PCS Committee, and the Board, and will report to the Board, PCAC, and PCS Committee on at least a quarterly basis using defined metrics against which performance will be measured.
Daunting, eh? You bet. Here's more. We will be publicizing our progress towards these goals on our external website for the world to see. In other words, we will be holding ourselves accountable to the public for our actions and deeds. Our steps towards transparency have just been notched up a level.
These Board votes certainly do not mean that we are not already doing a good job now. Our Boards have immense respect and affection for all of the staff who work in our hospitals. They know you take really good care of patients and provide a warm and caring environment for patients and families. But the votes mean that our Board members who represent the community want us to do even better, out of a sense of public service and also out of a sense of pride that we can do better.
Over the last several months, we have seen a hint of what is possible. Our efforts at infection control on the floors and in the ICUs are but a few examples. Meanwhile, too, we have made process and customer service improvements in a number of clinics. We have saved lives, reduced adverse events, improved customer satisfaction, and made life a bit less hectic for some of our staff. (You know from previous emails that I am working hard to make even more improvements on that latter point.)
We have come a long way. Six years ago, both of our hospitals were close to being sold or shuttered. Four years ago, we had passed through a turn-around and proved our ability to survive. These past two years, we have shown that we are vibrant members of the Boston and Harvard medical communities. Now, we rise to the largest challenge yet -- setting standards for patient satisfaction and reduction of harm that are truly world class.
Stay tuned as we roll this out and decide on the yearly priorities and work plans that will eventually lead to reaching these audacious goals. In the meantime, as always, please keep in touch with your ideas, suggestions, and criticisms.
Sincerely,
Paul
Here is Senator Moore's statement:
“BI-Deaconess deserves to be strongly commended for taking this challenging, bold step to improve health quality and transparency. By including a small community hospital (BID-Needham) as well as a major academic medical center, BI-Deaconess becomes a true champion of health care quality and patient safety. Their leadership in promoting transparency is unprecedented in the Commonwealth, and is fully consistent with the principles behind legislative initiatives such as Senate Bill No. 1277/House Bill No. 2226, An Act Improving Consumer Healthcare Quality. They obviously understand the meaning of 'First, Do No Harm.' They get it right!”
Thank you, Senator!
Tuesday, January 15, 2008
In Memoriam: Dr. Judah Folkman
Scott Allen at the Boston Globe and White Coat Notes reports on the death of Dr. Judah Folkman, a legendary researcher at Boston Children's Hospital. The fact that, as of this writing, 63 comments from the public were submitted to the online version of this report gives a sense of how this gentleman was regarded in Boston and beyond. Please read them for a sense of his widespread impact.
Our condolences go to Paula and her family and all of Judah's many friends.
Our condolences go to Paula and her family and all of Judah's many friends.
Monday, January 14, 2008
How to vote on Medgadget.com
No, this is not about hanging chads. I've talked to friends who say they have voted on http://www.medgadget.com/ for their choice of best blogs, but they have often done it wrong. If you just click on the name of the blog on the homepage or above the "ballot" on the voting pop-up page, it does not record as a vote. (In fact, all it does is to send you over to that website.)
To record a vote, you actually have find the page with the green ballot by clicking on the Medical Blog Awards trophy on the homepage and then clicking on the Please vote here link. Then put your cursor on the "hole" next to the blog of choice, click to leave a dot, and then click again on the bigger "vote" button, for your vote to be recorded.
So, regardless of your choice of candidates, if you did it wrong, you might want to return and vote again.
As I mentioned below, I would be honored to have your vote, in either or both categories: Best medical weblog or Best health policies/ethics weblog.
To record a vote, you actually have find the page with the green ballot by clicking on the Medical Blog Awards trophy on the homepage and then clicking on the Please vote here link. Then put your cursor on the "hole" next to the blog of choice, click to leave a dot, and then click again on the bigger "vote" button, for your vote to be recorded.
So, regardless of your choice of candidates, if you did it wrong, you might want to return and vote again.
As I mentioned below, I would be honored to have your vote, in either or both categories: Best medical weblog or Best health policies/ethics weblog.
On checklists
Lots of you have been asking me to comment on the story by Atul Gawande in the New York Times, in which he discusses a hospital that had to stop a quality improvement checklist program because of an adverse ruling by the federal agency that reviews human subject experiments. I really didn't know what more to say on this, in that Atul wrote the story in his usual brilliant manner, made the case clearly, and certainly got as much publicity for the cause as possible by its placement.
Meanwhile, though, a movement has started to make sure the government does not overreach in this area. Charlie Baker, for one, has written very well on the subject, and so, especially, has Bob Wachter. And I just received, through Bob, a copy of a letter from the American Hospital Association to Secretary Leavitt on the matter. I haven't heard anything about a reply from the Secretary. I know he has a blog, and this might be a good time to use it and reassure all of us.
Here is the AHA letter, in whole:
January 3, 2008
The Honorable Michael Leavitt
Secretary
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 615F
Washington, D.C. 20201
Dear Mr. Secretary:
In a December 30 New York Times op-ed piece, Dr. Atul Gawande raises important questions about a misguided and potentially dangerous policy of the Office for Human Research Protections that would impose an unprecedented deterrent to quality improvement efforts across the country. I am writing to ask you to immediately retract any statements from the Office of Human Research Protections that imply that quality improvement efforts should undergo review by Institutional Review Boards, and that consent should be obtained from all patients before changes could be incorporated.
As you know, hospitals across the nation are engaged in a variety of activities aimed at redesigning health care delivery systems to ensure that our patients get the best possible care we can deliver. Some of these activities are organized by hospitals, such as the Michigan Health and Hospital Association’s Keystone project that Dr. Gawande cites. Others include projects initiated by the Institute for Healthcare Improvement, the Quality Improvement Organizations funded by the Centers for Medicare & Medicaid Services, and the work of several professional societies and organizations such as the American College of Surgeons and the American College of Cardiology.
As Dr. Gawande points out, research to determine which drugs or procedures will benefit patients requires appropriate oversight by an Institutional Review Board (IRB) and informed consent by the patients. However, those efforts are far different from the quality improvement efforts exploring the use of checklists, computerized reminders, teamwork training, and other steps to ensure that the care we intend to deliver is actually delivered.
It is worth noting that hospitals and health care professionals are not the only ones engaged in such projects. The quality transparency efforts in which the AHA, the Department of Health and Human Services (HHS), and several other organizations have partnered, the local value exchanges your department has fostered, and the value-based purchasing initiatives you have championed are other examples. Yet, HHS has, quite reasonably, sought no IRB review or informed consent for these changes, because they, too, are intended simply to improve the delivery of care.
As quality improvement efforts become more standardized and rigorous, and as the data collection efforts that support this work become more extensive, it would be right and appropriate to contemplate how we can collaborate to ensure that the welfare of patients remains the central concern and that patient privacy is protected. It also would be appropriate to consider effective ways for hospitals and other providers to communicate with the public about their quality improvement efforts. However, it would be wholly inappropriate and detrimental to the patients and communities we serve if the measures apparently championed by the Office for Human Research Protections were to force hospitals and others to discontinue their quality improvement efforts.
On behalf of America’s hospitals, I urge you to ensure that the essential quality improvement efforts underway across the nation continue unabated.
Sincerely,
Rich Umbdenstock
President and CEO
Meanwhile, though, a movement has started to make sure the government does not overreach in this area. Charlie Baker, for one, has written very well on the subject, and so, especially, has Bob Wachter. And I just received, through Bob, a copy of a letter from the American Hospital Association to Secretary Leavitt on the matter. I haven't heard anything about a reply from the Secretary. I know he has a blog, and this might be a good time to use it and reassure all of us.
Here is the AHA letter, in whole:
January 3, 2008
The Honorable Michael Leavitt
Secretary
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 615F
Washington, D.C. 20201
Dear Mr. Secretary:
In a December 30 New York Times op-ed piece, Dr. Atul Gawande raises important questions about a misguided and potentially dangerous policy of the Office for Human Research Protections that would impose an unprecedented deterrent to quality improvement efforts across the country. I am writing to ask you to immediately retract any statements from the Office of Human Research Protections that imply that quality improvement efforts should undergo review by Institutional Review Boards, and that consent should be obtained from all patients before changes could be incorporated.
As you know, hospitals across the nation are engaged in a variety of activities aimed at redesigning health care delivery systems to ensure that our patients get the best possible care we can deliver. Some of these activities are organized by hospitals, such as the Michigan Health and Hospital Association’s Keystone project that Dr. Gawande cites. Others include projects initiated by the Institute for Healthcare Improvement, the Quality Improvement Organizations funded by the Centers for Medicare & Medicaid Services, and the work of several professional societies and organizations such as the American College of Surgeons and the American College of Cardiology.
As Dr. Gawande points out, research to determine which drugs or procedures will benefit patients requires appropriate oversight by an Institutional Review Board (IRB) and informed consent by the patients. However, those efforts are far different from the quality improvement efforts exploring the use of checklists, computerized reminders, teamwork training, and other steps to ensure that the care we intend to deliver is actually delivered.
It is worth noting that hospitals and health care professionals are not the only ones engaged in such projects. The quality transparency efforts in which the AHA, the Department of Health and Human Services (HHS), and several other organizations have partnered, the local value exchanges your department has fostered, and the value-based purchasing initiatives you have championed are other examples. Yet, HHS has, quite reasonably, sought no IRB review or informed consent for these changes, because they, too, are intended simply to improve the delivery of care.
As quality improvement efforts become more standardized and rigorous, and as the data collection efforts that support this work become more extensive, it would be right and appropriate to contemplate how we can collaborate to ensure that the welfare of patients remains the central concern and that patient privacy is protected. It also would be appropriate to consider effective ways for hospitals and other providers to communicate with the public about their quality improvement efforts. However, it would be wholly inappropriate and detrimental to the patients and communities we serve if the measures apparently championed by the Office for Human Research Protections were to force hospitals and others to discontinue their quality improvement efforts.
On behalf of America’s hospitals, I urge you to ensure that the essential quality improvement efforts underway across the nation continue unabated.
Sincerely,
Rich Umbdenstock
President and CEO
Pack up your troubles
From my friend John:
"I hope you are like this 109 year old Australian woman and are still blogging at 109 years old."
As you dig down into the site, check this link to hear and watch Olive sing "Smile, Smile, Smile". It is marvelous, especially the repeat halfway through the clip.
"I hope you are like this 109 year old Australian woman and are still blogging at 109 years old."
As you dig down into the site, check this link to hear and watch Olive sing "Smile, Smile, Smile". It is marvelous, especially the repeat halfway through the clip.
Exit interview
I am realistic enough to know that not everybody loves their job here and that people sometimes leave with hard feelings, but when you get a note like this months later from a medical technologist who spent two years with us, you have to feel good:
Hello Mr. Levy,
I had the most incredible experiences working at BIDMC and miss it so much! There is a palpable sense of community within the hospital that is almost impossible to find anywhere, especially in an urban setting. Trust me, I have had a few rotations around Boston and constantly yearn for the comfort and kindness of BIDMC employees. If it had not been for my wonderful position at the hospital and the strong support of my colleagues, I would have not gone back to graduate school to obtain my nurse/nurse practitioner degree.
I hope after my studies I may just find a path back to BIDMC. All the best to you and your hospital.
Hello Mr. Levy,
I had the most incredible experiences working at BIDMC and miss it so much! There is a palpable sense of community within the hospital that is almost impossible to find anywhere, especially in an urban setting. Trust me, I have had a few rotations around Boston and constantly yearn for the comfort and kindness of BIDMC employees. If it had not been for my wonderful position at the hospital and the strong support of my colleagues, I would have not gone back to graduate school to obtain my nurse/nurse practitioner degree.
I hope after my studies I may just find a path back to BIDMC. All the best to you and your hospital.
Sunday, January 13, 2008
Who's on first
A true story about cultural competence related by my friend Ed, who spent some time on a low budget trek through northern Africa after graduating from college in the 1970's.
While in Algeria, he met a young man who asked, "What is your name?"
Ed replied, "I am Ed."
"Really?" said the young man, "Ahmed is my name, too!"
"No," said Ed, "I AM Ed!"
"Yes, Ahmed!" replied the other.
While in Algeria, he met a young man who asked, "What is your name?"
Ed replied, "I am Ed."
"Really?" said the young man, "Ahmed is my name, too!"
"No," said Ed, "I AM Ed!"
"Yes, Ahmed!" replied the other.
For Inspector Gadget
Have secrets? This is just for you. A biometric memory stick for your computer. You drag your finger twice over the little sensor (the orange strip at the bottom end), and that encodes your fingerprint. Then, only you can get access to the data in your memory stick when you plug it into a computer, by again passing your finger over the sensor. (There is a sliding door to protect the sensor.)Am I a Luddite (don't answer that!), or is this a technology in search of a purpose? Maybe I don't have many secrets, but I think there will be limited demand for this. On the other hand, maybe I should add more intrigue to my life and find some secret data that I want to carry around with me.
Do you have secret data that you would want to protect this way? Hmm, is it HIPAA compliant to carry patient data in this manner? Perhaps our CIO, John Halamka, or others will comment on that.
(The company that makes this is call TwinMOS.)
Saturday, January 12, 2008
Whither thou goist I shall go
Back to our more interesting and important week's topic of helping others and giving back. Please read this lovely story by Irene Sage in today's Boston Globe about Ruth Adomunes, a BIDMC staff member who is helping to build a school in Haiti by making and selling bracelets.
I like the final paragraph: Wherever Adomunes goes, she carries a large tote bag filled with bracelets. "This is my portable store," she says. "If someone says, 'Do you have any bracelets?' 'Yes, I do.' "
I like the final paragraph: Wherever Adomunes goes, she carries a large tote bag filled with bracelets. "This is my portable store," she says. "If someone says, 'Do you have any bracelets?' 'Yes, I do.' "
Friday, January 11, 2008
>500 letters in the mailroom
Our mail room staff called today to say that over 500 letters had arrived from the SEIU to doctors in the hospital. One of the doctors was kind enough to share his with me, a letter from Mike Fadel, Executive Vice President. I'll spare you most of the details, but I will give you a small quote:
"BIDMC's CEO recently has complained that he has been singled out for public criticism on the 'question' of whether hospital workers should be promised that they will not be threatened by executives on the decision of unionizing. Be he has singled out his own institution by essentially promising to fight against BIDMC's own caregivers as if they were adversaries."
Those of you who are regular readers of this blog know that all of the above is not true. You know the high regard and respect I have for our employees, and you know of my personal efforts to improve the work environment at this hospital -- both for their sake and in support of providing better care to our patients. You can also see exactly what I have said about union organizing in general and the tactics of this union in particular.
The union's use of language is carefully chosen. It is meant, first, to isolate me by giving the impression that I am the only hospital CEO in Boston who feels this way. Not so. The others may not say so publicly, but they readily say so privately. (Who knows, perhaps they are wise to do it that way!)
Second, it is meant to try to create divisions between the doctors and the administration of the hospital. Not likely to be effective, either, in that the doctors see quite clearly what tactics are at play here.
A third subtle aspect of the package sent to the doctors is the inclusion of an op-ed from a Jewish newspaper that makes similar accusations and states that I am acting in a manner inconsistent with the "Jewish tradition of social justice." Months ago, I raised a hint as to this tactic as well. Perhaps the SEIU thinks that doctors at a hospital, one of whose antecedents was established by the Jewish community, would be receptive to this argument. Perhaps they don't understand that many people are likely to find it an offensive and mistaken use of religion in support of a political or organizational cause.
Meanwhile, I hear from friends on Beacon Hill that the union persists in complaining about this blog and what I say in it. What I say in it, as all of you know, is out there for the world to see and evaluate. If any of you catch me in a misleading comment or a mistake you can say so immediately and for the rest of the world to see.
Sunshine is the best disinfectant.
"BIDMC's CEO recently has complained that he has been singled out for public criticism on the 'question' of whether hospital workers should be promised that they will not be threatened by executives on the decision of unionizing. Be he has singled out his own institution by essentially promising to fight against BIDMC's own caregivers as if they were adversaries."
Those of you who are regular readers of this blog know that all of the above is not true. You know the high regard and respect I have for our employees, and you know of my personal efforts to improve the work environment at this hospital -- both for their sake and in support of providing better care to our patients. You can also see exactly what I have said about union organizing in general and the tactics of this union in particular.
The union's use of language is carefully chosen. It is meant, first, to isolate me by giving the impression that I am the only hospital CEO in Boston who feels this way. Not so. The others may not say so publicly, but they readily say so privately. (Who knows, perhaps they are wise to do it that way!)
Second, it is meant to try to create divisions between the doctors and the administration of the hospital. Not likely to be effective, either, in that the doctors see quite clearly what tactics are at play here.
A third subtle aspect of the package sent to the doctors is the inclusion of an op-ed from a Jewish newspaper that makes similar accusations and states that I am acting in a manner inconsistent with the "Jewish tradition of social justice." Months ago, I raised a hint as to this tactic as well. Perhaps the SEIU thinks that doctors at a hospital, one of whose antecedents was established by the Jewish community, would be receptive to this argument. Perhaps they don't understand that many people are likely to find it an offensive and mistaken use of religion in support of a political or organizational cause.
Meanwhile, I hear from friends on Beacon Hill that the union persists in complaining about this blog and what I say in it. What I say in it, as all of you know, is out there for the world to see and evaluate. If any of you catch me in a misleading comment or a mistake you can say so immediately and for the rest of the world to see.
Sunshine is the best disinfectant.
Dr. Codman was right then, and he is right now
Please check out this article by Doctors Swensen and Cortese from the Mayo Clinic. An excerpt:
Transparency was an issue for the American medical profession a century ago, and transparency is an issue for the American medical profession today. In 1905, Ernest Codman, MD, first described the "end result idea." The end result idea is simply that doctors should follow up with all patients to assess the results of their treatment and that the outcomes actively be made public. The end result idea was considered heretical at the time, but in retrospect Codman was sagacious and prescient. He was an advocate for transparency, which he believed would promote quality improvement, patient choice, and physician learning. Transparency is best viewed as an opportunity, one that we should fully and enthusiastically embrace. It offers a substantive boost as organizations step up to the moral imperative of improving patient care to the best it can be.
Codman "walked the walk" as well as "talked the talk." He openly admitted his errors in public and in print. In fact, he paid to publish reports so that patients could judge for themselves the quality of his care. He sent copies of his annual reports to major hospitals throughout the country, challenging them to do the same. From 1911 to 1916, he described 337 patients who were dismissed from his hospital. He reported 123 errors. He measured the end results for all. Codman passionately promoted transparency in order to raise standards. Codman said, "Let us remember that the object of having standards is to raise them."
...A century later, the medical profession is still struggling with the same issues as though they were new. Dr. Codman was right then, and he is right now. Fundamental to the quality movement and American medicine in the 21st century are the same peer review, standardization, systems engineering, and outcome measurement issues. Publishing results for public scrutiny remains a controversial topic. We should embrace transparency as a component of our tipping point strategy to ignite the change we all need to transform our organizations and our profession.
Transparency was an issue for the American medical profession a century ago, and transparency is an issue for the American medical profession today. In 1905, Ernest Codman, MD, first described the "end result idea." The end result idea is simply that doctors should follow up with all patients to assess the results of their treatment and that the outcomes actively be made public. The end result idea was considered heretical at the time, but in retrospect Codman was sagacious and prescient. He was an advocate for transparency, which he believed would promote quality improvement, patient choice, and physician learning. Transparency is best viewed as an opportunity, one that we should fully and enthusiastically embrace. It offers a substantive boost as organizations step up to the moral imperative of improving patient care to the best it can be.
Codman "walked the walk" as well as "talked the talk." He openly admitted his errors in public and in print. In fact, he paid to publish reports so that patients could judge for themselves the quality of his care. He sent copies of his annual reports to major hospitals throughout the country, challenging them to do the same. From 1911 to 1916, he described 337 patients who were dismissed from his hospital. He reported 123 errors. He measured the end results for all. Codman passionately promoted transparency in order to raise standards. Codman said, "Let us remember that the object of having standards is to raise them."
...A century later, the medical profession is still struggling with the same issues as though they were new. Dr. Codman was right then, and he is right now. Fundamental to the quality movement and American medicine in the 21st century are the same peer review, standardization, systems engineering, and outcome measurement issues. Publishing results for public scrutiny remains a controversial topic. We should embrace transparency as a component of our tipping point strategy to ignite the change we all need to transform our organizations and our profession.
Thursday, January 10, 2008
Inspiring and powerful
The theme this week seems to be "giving back" or "paying it forward." Here is another chapter.
Every Monday morning, I have the pleasure of welcoming new employees of BIDMC at an orientation session we hold for them. Later, there is a section in the program when we ask the new employees to think about a time they may have gone to a hospital for themselves or accompanied a loved one. In thinking about the experience, we then ask them to evaluate whether it was positive (and what made it so) or did not go well and what could have improved it.
Here's a note from the group leader, Lynda, about what happened this week:
Depending on the audience, some weeks we get all kinds of responses and then sometimes people are more reticent. This week, the audience was a bit quiet so I piped in with my own experience of having just gone through significant experiences of my own and how the kindness that I received from staff made a difference in my healing. I asked the group if anyone could “top that”.
A woman in the audience raised her hand and proceeded to tell all of us about the time, 4 years ago, when her father who was a patient here, was dying. She choked back tears as she told about her family all being there and the staff making sure everyone had a place to sleep and food to eat around the clock and whatever else they needed. They were apparently there for a number of days but went through the experience together as a family, with their father, being totally supported by the staff.
Then she added that she decided she wanted to come and work here in order to be able to give others the kind of experience she had here and to work with these remarkable people.
All in all, tearful and inspiring and powerful for all of us present.
Every Monday morning, I have the pleasure of welcoming new employees of BIDMC at an orientation session we hold for them. Later, there is a section in the program when we ask the new employees to think about a time they may have gone to a hospital for themselves or accompanied a loved one. In thinking about the experience, we then ask them to evaluate whether it was positive (and what made it so) or did not go well and what could have improved it.
Here's a note from the group leader, Lynda, about what happened this week:
Depending on the audience, some weeks we get all kinds of responses and then sometimes people are more reticent. This week, the audience was a bit quiet so I piped in with my own experience of having just gone through significant experiences of my own and how the kindness that I received from staff made a difference in my healing. I asked the group if anyone could “top that”.
A woman in the audience raised her hand and proceeded to tell all of us about the time, 4 years ago, when her father who was a patient here, was dying. She choked back tears as she told about her family all being there and the staff making sure everyone had a place to sleep and food to eat around the clock and whatever else they needed. They were apparently there for a number of days but went through the experience together as a family, with their father, being totally supported by the staff.
Then she added that she decided she wanted to come and work here in order to be able to give others the kind of experience she had here and to work with these remarkable people.
All in all, tearful and inspiring and powerful for all of us present.
Thank you, PHC
Stephen Smith at the Boston Globe reports that the state Public Health Council voted to allow storefront clinics in Massachusetts. (I had written in support of this vote last week.) CVS, the original proponent, apparently plans to open more than two dozen. Now, having gotten permission, CVS needs to carry this concept in a manner that will set a high standard and prove the wisdom of the PHC vote. I wish them well in introducing this innovation into the MA health care delivery system.
Wednesday, January 09, 2008
Don't let others define who you are
Each year, in cooperation with the Boston YMCA and in conjunction with the Martin Luther King, Jr. holiday, we present Black Achiever awards to members of our staff who have made significant contributions to the workplace and their community. We also invite a guest to offer a keynote address, and this year it was Rev. Dr. Michael E. Haynes, Senior Pastor Emeritus, at Roxbury's Twelfth Baptist Church. Rev. Haynes was a personal friend of Dr. King's, having met during the latter's training at Boston University. It was inspiring and enlightening to hear stories from that period.
Equalling inspiring, though, was the acceptance speech delivered by Dr. Yvonne Gomez-Carrion, an obstetrician in our hospital. I asked her for permission to post it here, and I include it in its totality.
---
Good afternoon! I am truly honored and humbled to be here today with all of you to celebrate the life of Dr. Martin Luther King, Jr. and to accept this Black Achiever award. I thank Dr. Ronald Marcus, my mentor and friend, for nominating me and for the committee for choosing me.
I have worked hard all of my life, and I have received so many, many blessings.
Yes, I have always loved being challenged. I love giving orders, and I love helping others work through difficult situations.
At age 8, I realized my calling: I wanted to be a doctor. So many individuals went out of their way to impress upon me how hard this path would be, and many told me that I would never make it as a physician, a healer.
I encountered so many negative people along my journey. The naysayers seemed to be everywhere, BUT those folks were trumped by my parents, many incredible mentors and dreamers like myself who inspired, promoted and assisted me at every opportunity .
I have been blessed to have friends who ARE encouraging, positive and like me, want to make a significant contribution to this world, to our community.
When I was told that I wasn't smart enough or that I couldn't go to the schools that I attended because my parents would not be able to pay, well I studied, received academic scholarships, and I sought out jobs that would give me insight into the medical world.
Growing up, I would get angry about the condition of my community in Brooklyn, NY, the lack stores with fresh and nutritious foods, the abundance of fast food and liquor stores, the lack of good medical and dental care and the many challenges to obtaining a good education.
The more angry I became, the harder I worked.
I never gave up: WITH HELP, I figured it out!
I appreciate that everyone needs to chart their own path. You need to figure out what you have passion for, what will bring you joy and satisfaction while giving back to your community.
I received countless valuable messages. These messages were pounded into my head by those who nurtured me.
They would say:
*Stick to your values.
*Don't let others define who you are.
*Surround yourself with positive people... My dad would always tell me, "Show me your friends and I will tell you who you are."
*Don't give up because things get rough.
*Have faith in yourself.
Life is full of disappointments and tragedies -- these provide the lessons that we must receive in order to grow.
I thank God for my family, friends, my amazing church community, my medical colleagues and my patients.
It is because of YOU that I stand here this afternoon!
Like Dr. Martin Luther King, Jr., I, too, dream and I challenge. Today, I challenge each and every one of you to:
*Seek out a child who is suffering from the ills of poverty, dangerous communities and substandard education.
*Seek out a child of color.
*Seek out a child with a learning difference.
*Seek out a child who feels that violence is the way.
REMEMBER, compassionate mentoring has the power to change and enrich another's life.
I AM A LIVING EXAMPLE OF THAT!
I will leave you with one of my favorite prayers, an "old healing prayer" from Central America:
Do all the good that you can
In all the ways that you can
By all the means that you can
To all the people that you can
In all the places that you can
For as long as ever YOU can
Thank you very much!!!
Equalling inspiring, though, was the acceptance speech delivered by Dr. Yvonne Gomez-Carrion, an obstetrician in our hospital. I asked her for permission to post it here, and I include it in its totality.
---
Good afternoon! I am truly honored and humbled to be here today with all of you to celebrate the life of Dr. Martin Luther King, Jr. and to accept this Black Achiever award. I thank Dr. Ronald Marcus, my mentor and friend, for nominating me and for the committee for choosing me.
I have worked hard all of my life, and I have received so many, many blessings.
Yes, I have always loved being challenged. I love giving orders, and I love helping others work through difficult situations.
At age 8, I realized my calling: I wanted to be a doctor. So many individuals went out of their way to impress upon me how hard this path would be, and many told me that I would never make it as a physician, a healer.
I encountered so many negative people along my journey. The naysayers seemed to be everywhere, BUT those folks were trumped by my parents, many incredible mentors and dreamers like myself who inspired, promoted and assisted me at every opportunity .
I have been blessed to have friends who ARE encouraging, positive and like me, want to make a significant contribution to this world, to our community.
When I was told that I wasn't smart enough or that I couldn't go to the schools that I attended because my parents would not be able to pay, well I studied, received academic scholarships, and I sought out jobs that would give me insight into the medical world.
Growing up, I would get angry about the condition of my community in Brooklyn, NY, the lack stores with fresh and nutritious foods, the abundance of fast food and liquor stores, the lack of good medical and dental care and the many challenges to obtaining a good education.
The more angry I became, the harder I worked.
I never gave up: WITH HELP, I figured it out!
I appreciate that everyone needs to chart their own path. You need to figure out what you have passion for, what will bring you joy and satisfaction while giving back to your community.
I received countless valuable messages. These messages were pounded into my head by those who nurtured me.
They would say:
*Stick to your values.
*Don't let others define who you are.
*Surround yourself with positive people... My dad would always tell me, "Show me your friends and I will tell you who you are."
*Don't give up because things get rough.
*Have faith in yourself.
Life is full of disappointments and tragedies -- these provide the lessons that we must receive in order to grow.
I thank God for my family, friends, my amazing church community, my medical colleagues and my patients.
It is because of YOU that I stand here this afternoon!
Like Dr. Martin Luther King, Jr., I, too, dream and I challenge. Today, I challenge each and every one of you to:
*Seek out a child who is suffering from the ills of poverty, dangerous communities and substandard education.
*Seek out a child of color.
*Seek out a child with a learning difference.
*Seek out a child who feels that violence is the way.
REMEMBER, compassionate mentoring has the power to change and enrich another's life.
I AM A LIVING EXAMPLE OF THAT!
I will leave you with one of my favorite prayers, an "old healing prayer" from Central America:
Do all the good that you can
In all the ways that you can
By all the means that you can
To all the people that you can
In all the places that you can
For as long as ever YOU can
Thank you very much!!!
Elections everywhere!
Many thanks to the folks at Medgadget for including me as a finalist in two categories of their 2007 Medical Weblogs Awards. I am ambivalent about the voting, as I am blogosphere "friends" with some of the competitors in both categories, and I have great respect for all of them.That being said, I would be honored to have your vote in this election, if you think this blog is worthy.
Federal campaign laws apply to this contest. No cash contributions above the legal limits, please. And, I do not accept contributions from tobacco companies . . . .
Tuesday, January 08, 2008
Pay it forward
Of all the great things that happen at BIDMC, the most satisfying to me is when we are able to help people realize their dreams and rise through the ranks of the health care and research fields.
Tonight, we held a graduation dinner for the first group of surgery tech's, ED tech's, and others who have completed their nursing degrees and will now be working in the hospital as RNs. Over two years ago, we chose employees to be sponsored in this program through a competitive process that took into account educational attainment to date, college placement test scores, and job performance. We paid for the tuition and books and fees at Mass Bay Community College, but these young folks put in the sweat equity, working after hours and on weekends. They were joined at the congratulatory dinner tonight by their friends and families, college officials, as well as their supervisors and mentors at the hospital. The special guest speaker was the Chair of our Board of Directors, Lois Silverman, who herself was the beneficiary of a similar program decades ago, when she received a $300 scholarship to attend the Beth Israel School of Nursing.
This is but one of several program that we have in place to provide career and professional advancement to people in the hospital, especially lower wage workers. These are funded out of our regular operating budget, from philanthropic donations, by a grant from The Boston Foundation, and by a grant from the Commonwealth of Massachusetts.
Another program is one that enables people to become surg tech's. Here, we partnered with Mass Bay to offer modified academic programs in a format that allows employees to continue to work full-time while pursuing their career-advancing education. Courses are offered at the hospital in the evenings or online, with labs taking place on weekends at college and clinical rotations on site. We provide funds to cover students' tuition and also a stipend to help them meet living expenses during the second half of the program, when their 24 hours of weekly clinical practicum require that they reduce their regular work hours.
Still another program is training people to be research administrators, a growing area in the world of academic medicine. Another we are kicking off will train people to be medical lab tech's, a tremendous growth field, as well. Yet another provides more elementary training in math and English to help people get to the level that they can participate in more advanced training.
It is, of course, greatly satisfying that people will earn more money as they move up the career ladder and have more opportunities. But what means more to me is that we are continuing in a tradition that reinforces the American Dream. Through hard work, persistence, dedication -- and a helping hand -- men and women can gain greater personal and professional satisfaction in their work and and, in turn, look back to help the next group coming through.
Tonight, we held a graduation dinner for the first group of surgery tech's, ED tech's, and others who have completed their nursing degrees and will now be working in the hospital as RNs. Over two years ago, we chose employees to be sponsored in this program through a competitive process that took into account educational attainment to date, college placement test scores, and job performance. We paid for the tuition and books and fees at Mass Bay Community College, but these young folks put in the sweat equity, working after hours and on weekends. They were joined at the congratulatory dinner tonight by their friends and families, college officials, as well as their supervisors and mentors at the hospital. The special guest speaker was the Chair of our Board of Directors, Lois Silverman, who herself was the beneficiary of a similar program decades ago, when she received a $300 scholarship to attend the Beth Israel School of Nursing.
This is but one of several program that we have in place to provide career and professional advancement to people in the hospital, especially lower wage workers. These are funded out of our regular operating budget, from philanthropic donations, by a grant from The Boston Foundation, and by a grant from the Commonwealth of Massachusetts.
Another program is one that enables people to become surg tech's. Here, we partnered with Mass Bay to offer modified academic programs in a format that allows employees to continue to work full-time while pursuing their career-advancing education. Courses are offered at the hospital in the evenings or online, with labs taking place on weekends at college and clinical rotations on site. We provide funds to cover students' tuition and also a stipend to help them meet living expenses during the second half of the program, when their 24 hours of weekly clinical practicum require that they reduce their regular work hours.
Still another program is training people to be research administrators, a growing area in the world of academic medicine. Another we are kicking off will train people to be medical lab tech's, a tremendous growth field, as well. Yet another provides more elementary training in math and English to help people get to the level that they can participate in more advanced training.
It is, of course, greatly satisfying that people will earn more money as they move up the career ladder and have more opportunities. But what means more to me is that we are continuing in a tradition that reinforces the American Dream. Through hard work, persistence, dedication -- and a helping hand -- men and women can gain greater personal and professional satisfaction in their work and and, in turn, look back to help the next group coming through.
What about the other bugs? Every day . . .
Isn't is odd, as noted below, that a norovirus outbreak causes health care workers to wash their hands, while the pervasive existence of the normal strains of bugs in hospitals -- some far more dangerous -- doesn't seem to be as persuasive in convincing people to use proper hand hygiene?
Norovirus? Try "happy birthday to you"
A few months ago, we had a problem with the norovirus at our Needham hospital. It is a nasty bug that causes stomach flu-like symptoms. And, after you get over it, you can be reinfected. I note in today's Globe that it has appeared in some other health care facilities around town.
Hand-washing is the best solution, but you have to wash your hands for something like 20 seconds -- long enough to sing "happy birthday to you" while you are washing after using the toilet! But, then you have to be careful not to touch the handle of the faucet, the door handle in the rest room, and so on, because the bug persists on surfaces. Obviously, it is very important for food service workers to use extra precautions as well, in that the cafeteria can be a place where this virus is spread.
Hand-washing is the best solution, but you have to wash your hands for something like 20 seconds -- long enough to sing "happy birthday to you" while you are washing after using the toilet! But, then you have to be careful not to touch the handle of the faucet, the door handle in the rest room, and so on, because the bug persists on surfaces. Obviously, it is very important for food service workers to use extra precautions as well, in that the cafeteria can be a place where this virus is spread.
Monday, January 07, 2008
Nice work from the docs and geeks
A note from two of our doctors to share with you. This is nice work, reflecting the kind of interdisciplinary approach to research that is possible in academic medical centers.
Dear Paul,
We thought the attached study [here is the abstract] from our group in the BIDMC Department of Neonatology and the Division of Clinical Computing might be of interest given your focus on assessing health care system performance. This paper uses computer based simulation techniques to examine how change brought on by the availability of new technology affects clinical outcomes, system performance and costs in a regionally distributed system of health care. The specific care technology examined is the use of induced hypothermia for the treatment of asphyxiated infants.
Although these approaches have long been used in other industries to identify optimal strategies to improve costs, quality and efficiency they have only rarely been applied to health care. We believe this modeling paradigm has great promise in studying how health systems respond to change brought on by policy decisions, the availability of new technologies, or natural/man-made disasters.
We hope you find it of interest.
Regards
Jim Gray and John Zupancic
Dear Paul,
We thought the attached study [here is the abstract] from our group in the BIDMC Department of Neonatology and the Division of Clinical Computing might be of interest given your focus on assessing health care system performance. This paper uses computer based simulation techniques to examine how change brought on by the availability of new technology affects clinical outcomes, system performance and costs in a regionally distributed system of health care. The specific care technology examined is the use of induced hypothermia for the treatment of asphyxiated infants.
Although these approaches have long been used in other industries to identify optimal strategies to improve costs, quality and efficiency they have only rarely been applied to health care. We believe this modeling paradigm has great promise in studying how health systems respond to change brought on by policy decisions, the availability of new technologies, or natural/man-made disasters.
We hope you find it of interest.
Regards
Jim Gray and John Zupancic
Sunday, January 06, 2008
Glass 60% empty
Patient Dave sent me this quote from today's New York Times: "As of 2006, nearly 60 percent of doctors polled by the American College of Physician Executives said they had considered getting out of medicine because of low morale, and nearly 70 percent knew someone who already had." How do you feel about this?
Keeping up with Jones
Every now and then, a bright, young, energetic faculty member shows up with an outrageous idea, and we thoughtful, mature, seasoned clinical and administrative leaders say, knowingly, "Sure, go ahead, with our blessings." We know that his or her chances of success are minimal, but we don't have the heart to be discouraging. And then -- of course -- we are proven wrong when the young doctor produces a great success.
Such was the case with Dr. Dan Jones, a surgeon specializing in minimally invasive surgery (MIS). His idea was to create a center for skills training and assessment in MIS, with the thought that surgeons throughout the city would use it to learn and be assessed on a regular basis. His Chief and I, knowing the petty rivalries that exist in this town, knew it was impossible.
So, here we are just a few years later, and the center exists. It is called the Carl J. Shapiro Simulation and Skills Center and is supported by Mr. Shapiro's family foundation, by industry donations, other philanthropy, and the hospital and Harvard Medical School. And, as noted in this recent article by Liz Cooney, it is now an essential part of the surgical training at our hospital. And, people from all over town come to use it, as well. CRICO/RMF, the Harvard-affiliated hospitals’ liability insurer, gives surgeons a $500 voucher for a refresher course and another $500 rebate on their malpractice insurance from CRICO/RMF upon successful completion of the course.
Thanks, Dan, for proving us wrong!
Such was the case with Dr. Dan Jones, a surgeon specializing in minimally invasive surgery (MIS). His idea was to create a center for skills training and assessment in MIS, with the thought that surgeons throughout the city would use it to learn and be assessed on a regular basis. His Chief and I, knowing the petty rivalries that exist in this town, knew it was impossible.
So, here we are just a few years later, and the center exists. It is called the Carl J. Shapiro Simulation and Skills Center and is supported by Mr. Shapiro's family foundation, by industry donations, other philanthropy, and the hospital and Harvard Medical School. And, as noted in this recent article by Liz Cooney, it is now an essential part of the surgical training at our hospital. And, people from all over town come to use it, as well. CRICO/RMF, the Harvard-affiliated hospitals’ liability insurer, gives surgeons a $500 voucher for a refresher course and another $500 rebate on their malpractice insurance from CRICO/RMF upon successful completion of the course.
Thanks, Dan, for proving us wrong!
Saturday, January 05, 2008
Night Falls
Another in my occasional series of artists and performers. This painting is by Deborah Kravitz, who works at BIDMC. Here is her statement.Mystery and the poignance of change are themes of my “Night Falls” paintings. The light of day moving into night brings change to the look of the land and opens channels into my heart and mind.
The “Night Falls” paintings are imaginary, however, they were influenced by my trip to Mulranney, a remote West Irish village. Eerie extended twilights, a result of Mulranney’s geographic position, give the evenings a magical quality. Visually exciting, evocative contrasts abound, rapidly changing weather and light on fields that look both lush and oddly barren. These paintings are reflections of my inner world as well as Irish landscape.
The medium is acrylic paint on prepared masonite panel. I create a gestural, monochromatic underpainting by manipulating paint with both additive and subtractive techniques. The image is developed by additional layers of transparent color.
Deborah Kravitz 2007
Deborah Kravitz 2007
Thursday, January 03, 2008
Looking back after six years at BIDMC
A long post. I hope you enjoy it.
As I approach my sixth anniversary this week as CEO of BIDMC, I thought you would find it interesting to join me in reviewing two of my earliest communications with the staff of the hospital. When I arrived, the hospital was in dire financial straits, morale had plummeted, and there was an associated exodus of doctors, nurses, patients, and community support.
The Attorney General of Massachusetts, Tom Reilly, had watched the place deteriorate for many years and understandably had little confidence in its ability to survive as an academic medical center. Therefore, to ensure that the beds at the hospital would be available into the future for the good of the public, he was pressuring the Board of Trustees to sell the hospital to a for-profit hospital chain and end its life as an academic medical center. Tom and I had had a long-term mutually respectful and friendly relationship, and I had met with him the previous week and tried to persuade him to give me a short amount of time to turn things around. He agreed, saying, "Because you are personally willing to take this on, I am willing to give you a chance." (By the way, hearing that kind of sentiment from an AG is bit intimidating!) He placed strong and sensible demands on me and the Board to produce a plan, with strict financial milestones, and a commitment to regular reports on our progress.
The staff knew none of this last matter until I arrived and told them.
So the first email I sent was dated Monday, January 07, 2002 at 11:48 AM, roughly four hours after I started work, and was simply entitled "Message for BIDMC". Those of you who have been involved in business turn-arounds will find familiar elements from your own activities. For those of you who have not, this might provide an interesting vicarious experience.
I am honored and pleased to join Beth Israel Deaconess Medical Center as President and Chief Executive Officer, and I look forward to getting to know many of you personally. This is a wonderful institution, representing the best in academic medicine: exemplary patient care, extraordinary research, and fine teaching. However, the place is in serious trouble, and we are going to have to work very hard during the next few months if we are to secure our future as a non-profit academic medical center.
I promise to have an open administration, sharing with you as much information as possible to help you be part of solving the problems of the medical center. Here is where things stand, as of today. Over the last several years, during one of the greatest economic booms in American history, hundreds of millions of dollars of the BIDMC's assets have gone toward paying the operating losses of the hospital. This was money that ordinarily would have been used as the source of funds for new facilities and equipment, for expansion of programs, and as a cushion for hard economic times. For whatever set of reasons, there was a failure to act to stop this financial outflow. We now face our last chance to reverse this problem.
The CareGroup and BIDMC Boards have a fiduciary responsibility to preserve the assets of this charitable organization to serve the public good. The Attorney General of the Commonwealth has the authority and responsibility to review the Boards’ progress in doing so. Because of the current state of the hospital's finances and because of its curious inability to make decisions during the past several years, some observers believe that the best way to preserve those assets is to sell the BIDMC to a for-profit hospital. This would ensure that the beds currently serving the public would continue to do so. In addition, the proceeds of such a sale, after paying off all of the hospital’s debt, would be placed in a community foundation to support healthcare services and programs in the region.
The good news is that my appointment by the BIDMC and CareGroup Boards means that any plans to sell the hospital are, for the time being, off the table. Frankly, I would not have taken the job unless I received that commitment -- because I know we can succeed. My assignment over the next few months is to take steps that will convince the Boards that saving the BIDMC as a non-profit academic medical center is a wise decision. I will be offering a specific plan for doing that, and we will be held accountable to extremely rigorous milestones. If we fall behind -- either because of a lack of will or a lack of ability to implement changes -- the result will be clear.
What specifics steps will we take? I will announce these over the coming days and weeks. As you know, The Hunter Group [note: a management consulting firm] is soon to submit their recommendations to us. Having seen earlier drafts of these recommendations, I can tell you that many of them are sensible and well thought out and way overdue. I am less certain that other recommendations are relevant to us, but all of them will get a thorough review by the administrative and medical leadership of the hospital. In addition, all of you will get a chance to review them and send comments to me, as they will be posted on our website.
Our review will result in detailed implementation plans and milestones for completion. One clear recommendation will be a reduction of staff throughout the hospital. While the exact number is not yet clear, several hundred positions will be eliminated to bring our level of staffing down to what can be supported by our clinical volumes. Layoffs are distasteful, uncomfortable, and scary, but we will carry them out as humanely as possible and treat people with respect and dignity. The many people who remain will be part of a more efficient medical center, and one that will be able to continue to carry out our important mission.
I have not taken this job to be part of a failure. I have taken it because I believe in you, your commitment, and your ability to succeed through this period of adversity. I am looking forward to showing the world what we can accomplish together.
Sincerely,
Paul Levy
A month later, after some very intense work, we put together the Recovery Plan. Here is the introduction to the document which was posted on the hospital's website.
Recovery Plan for the Beth Israel Deaconess Medical Center
February 1 , 2002
To: The Executive and Finance Committees of the Board of Trustees of the Beth Israel
Deaconess Medical Center
From: Paul F. Levy, President and Chief Executive Officer
Over the past several years, the BIDMC has run large, persistent deficits. The medical center has now reached the point where strong, effective, and immediate action is required to reverse this trend. The alternative to these steps will be a noticeable diminution in the quality of care offered by the hospital and a depletion of the assets that are held in the public’s trust. Neither of these results is acceptable.
This plan is a result of a concerted effort on the part of the medical and administrative staff over the past several weeks. It represents a level of teamwork and commitment that is extraordinary and unique in the history of this institution. It is designed to provide immediate financial relief, leading to long-term financial health. However, a financial plan for a hospital like the BIDMC must represent more than a simple reduction in expenses: The trademark of this hospital is its reputation for a warm, caring environment within which patients and their families receive the finest in medical care. Our record on patient satisfaction is extraordinary. If the BIDMC fails to maintain this mission, it will fail. Accordingly, where a decision to implement an activity with potential short-term financial gain conflicts with patient care, we have chosen to err on the side of maintaining patient care. Such choices do not undermine the financial recovery plan: They enhance it.
The healthcare market in Boston is highly competitive, and some have asked whether it is necessary for the BIDMC to exist as an academic medical center. These observers state that the key attribute of the BIDMC is the number of beds it has in service to the public, and that preservation of these beds should be the major goal facing the community. We reject this premise. While retention of beds is an important public health goal, the existence and enhancement of the BIDMC’s role as an academic medical center is also of vital importance to the Boston area medical community and beyond.
Academic medical centers, in general, are regional and national treasures that provide the public with more than high quality health care. They are the cauldrons of innovation in medicine, places in which research flows seamlessly from bench to bedside and back. Physician scientists observe symptoms and trends in patient care, carry hypotheses about the origin and treatment of disease to the laboratory for analysis and testing, and then transport laboratory results back to the clinic. The BIDMC is a national leader in biomedical research. That status is a result of peer reviews of BIDMC research proposals carried out by medical research scientists throughout the country. Scientists at the BIDMC conduct millions of dollars in research funded by the NIH and by foundations like the American Cancer Society, the American Heart Association, and the American Diabetes Association, reflecting the confidence of these organizations in the quality of science carried out here. In total, the BIDMC carried out $140 million in research last year, of which most supported the direct costs of the research and $34 million went to support indirect costs. Many of our scientists are the international leaders in their respective fields and play key roles in setting national research priorities through their roles in study sections and advisory boards. There are direct results from this research in place now throughout the world. Our research enterprise generates new intellectual property on a continuous basis, and this produces sponsored research programs funded by pharmaceutical companies, as well as start-up companies based on our technologies in which the medical center participates. Patients benefit from this research agenda directly when such research is applied but also by the fact that the existence of this effort encourages the very best doctors to practice at the BIDMC.
Academic medical centers are also the training ground for future physicians. As in the case of research, the interplay between education and patient care is extraordinarily important. The opportunity to work with and train an outstanding group of medical students and residents is a major attraction that draws the highest quality staff physicians to a world-class medical center such as BIDMC. Practicing physicians will also tell you that their involvement in training medical students and residents requires those physicians to maintain their professional edge, keeping current with the latest advances in clinical care. Trainees at all levels will report that their experience in the halls of the hospital is critical to their education as doctors. This phenomenon has been recognized by the federal government by its funding of medical residents through the Medicare program. At Beth Israel Deaconess, we receive approximately $53 million annually for graduate medical education (the training of residents and subspecialty fellows).
The BIDMC is a leader in medical education at all levels. Our physicians provide approximately one-third of the clinical instruction of Harvard Medical School students, offering training in the following fields: internal medicine, surgery, obstetrics and gynecology, neurology, psychiatry, orthopedics, radiology, pathology, anesthesiology, emergency medicine, dermatology, radiation oncology, and neonatology. At the residency level, the BIDMC offers training in all of the above fields to an annual incoming residency class of approximately 125 men and women (for a total complement of approximately 450 residents over their several years of training). An additional 160 physicians receive more advanced subspecialty training in a wide variety of disciplines.
Does the BIDMC need to exist and carry out these functions, or should it devolve into a community hospital, offering a range of medical specialties to the public? This is a plan that has been put forth by some observers. We think it is shortsighted. While it could be argued that the BIDMC’s scientists and teachers could go elsewhere, such an argument leads to a reductio ad absurdum result. The same could be said for every academic medical center. How are we to choose which organization should live or die?
We are realistic enough to know that, in today’s environment, the answer will be guided by the underlying finances of the institution. Unless the BIDMC is able to maintain its clinical programs in a manner consistent with fiscal responsibility, it will not be able to generate sufficient support to remain as an academic medical center. This plan is a blueprint that will support that result. The issue for the BIDMC is not so much whether it should remain an academic medical center: Rather, we will need to decide what mix of clinical care, research, and teaching can be supported. To date, the financial systems and institutional structures of the BIDMC have foreclosed making those decisions. As a result of changes we will make, those choices will be apparent, and decisions will be made about the programmatic priorities for the hospital.
The recovery plan is guided in great measure by the recommendations of The Hunter Group ("THG"). The report prepared by THG has been made available to every employee in the medical center, and we have received hundreds of suggestions and comments regarding the implementation of the measures contained therein. Every one of these suggestions has been considered by senior management. There is much that is good in THG report. It sharpens the focus of our efforts, offering a range of specific financial targets we must achieve. Many of the recommendations of THG are correct, and in fact reinforce those of previous consulting firms. We embrace those recommendations wholeheartedly and have already started implementing many of them. Other THG recommendations are correct insofar as their purpose and goal, but need modification with regard to implementation. In this proposed recovery plan, we commit to achieving the financial results of such measures set forth by THG, but we promulgate a more realistic plan for achieving them. A small number of THG recommendations are unsupported and impractical and have been dismissed. Finally, we offer a set of our own recommendations that were not proposed by THG.
Our recovery plan has a clear financial target. Progress towards that target will be presented to the Board, and it is measurable at every step along the way. We have considered THG’s recommendation that our approach should be to reach a goal of a 3% margin on clinical care within the next two-and-a-half years. This is not realistic given our plan to maintain high quality patient care and, if achieved, would place the BIDMC in a range of performance seldom achieved by academic medical centers. It also would place an undue strain on an institution that will already face massive organizational challenges.
Inherent in our target is a need to stem the "run rate", the degree to which hospital operations are depleting the unrestricted assets of the corporation. We must and will demonstrate a dramatic reduction in the run rate throughout the remaining months of fiscal year 2002. Clear targets for fiscal year 2003 and 2004 are also presented, leading to a break-even result in fiscal year 2004. In the interim, we believe it is appropriate to budget a certain level of operational support from the endowment for three purposes: to compensate for the institution’s past lethargy in making operational improvements; to support the level of research and teaching that are critical to the overall success of this academic medical center; and to serve as a venture fund to finance strategic initiatives that will bring longer term revenue enhancement and quality improvement in this hospital.
On the revenue side of the ledger, we project no increase in patient volumes for fiscal year 2002, but we do commit to a modest increase in such volumes in 2003 and 2004. This contrasts with THG report, which has no expectations of such revenue growth. This commitment is offered by the chiefs and the medical staff directly. It reflects the substantial financial investment being made to recruit a number of the excellent surgeons to this hospital. It relies, too, on increasing physician productivity, particularly with regard to ambulatory care. Finally, it rests in great measure on enhancing relationships with referring physicians throughout the Boston area. The physicians are directly accountable for the success of this recovery plan, and they are willing and ready to stand by that commitment.
Also, on the revenue side, we show income from the rental of real estate. This measure reflects the surfeit of space in the medical center, relative to the size of its clinical and academic functions. That the amount included in our rental projections is achievable reflects inquiries and commitments made during the last several weeks, as well as our own estimate of future tenancies. In choosing to rent space, we will limit ourselves to tenants which have a strategic synergy with the medical center -- organizations which conduct medical research and clinical care that is consistent with our mission and with which we are likely to want to maintain a close relationship over the coming years.
How can the Board best measure our progress in carrying out this plan? Of course, we will provide month-to-month figures on patient volume and financial performance. The advantage of such real-time data is that it offers the potential to track early indicators, but the disadvantage is that any given month’s figures can also cause misleading hope or discouragement. Obviously, it is only the trend over several months that is meaningful.
The difficulty of measuring the success of our program is inherent in the nature of this medical center. The preponderance of our costs are fixed, but the preponderance of our revenues are variable. Even a small shift in patient volumes can cause large swings in the month-to-month bottom line. This problem is aggravated by the fact that the hospital has and will invest large sums of money in the potential for future growth. We have large commitments to recruitments in surgery and anesthesia, for example. Likewise, our physical plant and equipment is sized for a larger patient volume than currently exits.
If we were in the manufacturing business, we would shed workers, close down divisions, and sell assets in the face of a downturn in volume – in essence, adjusting the fixed cost base to be commensurate with a reduction in revenue. Here, our investment commitments are not so variable or fungible. Our staff is our key resource. We cannot increase and decrease the numbers of doctors, nurses, and technical staff every quarter in response to volume changes. Neither can we buy and sell property and reconfigure operating rooms and other patients facilities every several months.
If we were financially healthy, we could deal with these variations by drawing on our "bank account" of unrestricted reserves, knowing that those reserves would be replenished in good times. Here, we have done this for a number of years but without replacing those funds, thus severely restricting the amount available for future use. As THG notes, time is running out if we intend to use those reserves in that manner for much longer. We are proposing a dramatic reduction in this practice, but, as noted above, some continued drawdown of these funds should be expected over the next two-and-a-half years as we pay off the investment costs needed to bring about a longer term level of sustainable patient volumes.
The major portion of this submission is our plan. In that section, we present our major initiatives in Quality of Patient Care; Revenue and Volume Growth; Expense Management; and Strategic Direction. We also provide a narrative comparison with THG’s recommendations in each area.
Our report also contains a series of charts presenting the financial summary for BIDMC that is our target for fiscal years 2002, 2003, 2004. We show projected overall financial results for each year, along with a month-by-month projection of the run rate during this period. These figures are presented alongside those offered by THG. Accompanying these figures is a summary of the performance monitoring tools and metrics that will be in place to measure our success in meeting these financial targets.
Finally, for ease of review, we present a chart in which we present each of the 200-plus THG recommendations and its projected effect in each of the three fiscal years. In the same chart, there is a narrative indicating the degree to which we accept the recommendation along with the financial target associated with our plan for each of the three fiscal years.
Before closing, I must address the concern that has been raised by THG and by other observers: Does the medical center have the ability and the will to carry out these recommendations? Many of the THG recommendations have been offered by previous consultants and yet were not carried out. Why is the situation different now?
Let us briefly review the reasons for the institution’s past failure. Recall that BIDMC had previously engaged Ernst and Young, Deloitte and Touche Consulting, and CSC as consultants to offer advice on achieving financial improvements. These firms independently developed many good ideas which significantly overlapped each other; so the turnaround plans did not fail because of a lack of ideas. While certain aspects of each plan may not have been totally achievable, the majority of the initiatives could have been accomplished.
One of the problems encountered was that the financial target that was established was too small. For example, the 1999 Genesis project stated the budget problem as $52 million per year. In the course of that effort, opportunities were identified totaling $95 million, of which management agreed to implement $75 million, of which about $59 million was actually achieved. However, the projected budget problem increased from $52 million to approximately $100 million during that period.
Another problem was that of unrealistic expectations. The 2000-2001 turnaround plan placed significant reliance on the establishment of a profitable partnership with a pharmaceutical or bio-tech company. The confidence expressed by senior management in this highly uncertain venture was not supported by evidence from outside the organization. In addition, knowledgeable people within the medical center who doubted its efficacy were treated as nay-sayers, and their voices were stilled or discounted.
A third problem was a failure to mesh broad views of how things would improve with the process of change within the organization. The plan developed in 2000 was announced before determining if certain key elements of its design could be accomplished. This conceptual "model" emerged as a "plan" before details could be developed, and the plan was immediately challenged at the detail level in a confrontational manner. Rather than a rational evaluation of the concepts, details were challenged: Decisions were then made in response to the confrontations. Senior management underestimated the reaction to the plan and was distracted by internal and external politics and publicity. As a result, it was difficult to address the very complex implementation and management issues inherent in the change process.
Significantly, a sense of urgency in the medical center had not been established prior to the announcement of this or any previous plan. While BIDMC senior leaders understood the urgency, they overestimated how successful they had been in communicating that sense and establishing it more broadly in the hospital. In part, too, many physicians did not accept the urgency because of a belief that a merger with Partners Healthcare system could occur; that a break-up of CareGroup would solve the problems of the BIDMC; or that Harvard Medical School and Harvard University would act as saviors.
During this last effort, a clear vision for the BIDMC was not accepted. The result was a failure to develop a guiding coalition of key physicians, managers, and Board members, resulting in an inability to remove obstacles to a new vision. This led to a failure to put the needs of the organization ahead of the individual needs and desires of its many internal constituencies. Suggestions that really could have made a difference were not accepted.
Finally, the last turnaround plan had a strong dependence on increasing clinical volumes, especially of high level tertiary and quaternary care. However, the lack of confidence on the part of specialty physicians in the future of the hospital led to faculty turnover that increased the volume gap. Meanwhile, remaining physicians did not fundamentally alter their practice to spend more time on clinical activities.
How is the current situation different? First and foremost, there is now a clear understanding on the part of the medical and managerial staff that the "platform is burning." The decision by the CareGroup Board of Directors to consider seriously the sale of the hospital is now widely known and has provided strong motivation to all parties to work on solving the institution’s financial problems. The involvement of the Attorney General of the Commonwealth, given his statutory responsibility with regard to public charities, underscores the fact that the Board of Directors will be held accountable for its fiduciary responsibilities, lending even greater credibility to that potential threat.
Second, we have shared with the entire hospital the contents of the Hunter report. This independent analysis offers a sobering conclusion about the future of the medical center, absent effective action. It offers detailed proposals for action within every department. It provides us with the tools to establish a realistic financial target, based on appropriate estimates of inflation in personnel and supply costs. It also provides objective criteria by which corrective actions can be judged. Broad-based knowledge of these aspects is key to success, and the report has received over 100,000 hits on the company intranet, and there have been thousands downloads of all or a portion of it. This is an unprecedented distribution of a management consulting report in an academic medical center. (We will follow up with a similar distribution of this plan.)
Third, we have created an environment in which suggestions and contributions from the broad base of physicians and employees are welcomed, solicited, and evaluated. Even if all of these ideas are not adopted, the fact that we have asked is an important aspect of building a constituency for the final decisions. We have created a culture that will avoid failure because the needs of the organization are clearly considered along with the needs and desires of individuals. Suggestions that really can make a difference will be accepted.
This is not to say that the path is easy or straightforward. While the physician leadership and individual physicians care deeply about the future of the BIDMC and are actively engaged in this effort, the day-to-day decisions of those physicians will depend on the creation of institutional incentives (both between the hospital and HMFP and within HMFP) that clearly align the financial and operational incentives of individual faculty practices and the hospital. Likewise, nurses and technical workers on whom we rely so much for the care of patients will need to make adjustments in the way they carry out their work, while maintaining the overall quality of care. Administrative staff will have to focus on the fact that they are part of the overhead cost in an organization the core mission of which is to serve patients and families, and so they will need to be engaged in continuous improvement and searches for greater efficiency.
The foundation for these efforts, though, has been poured. The spirit of the hospital is strong, and the commitment of those working here is as intense as ever. In summary, we offer a financial plan that is real and achievable, but we recognize the tremendous effort that will be required to achieve it. The plan satisfies the fiduciary responsibilities of this Board of Trustees. First and foremost, it promises our patients and their families that the quality of care they receive at this hospital will meet the high standards they expect. Equally important, it ensures that the public’s trust with regard to the preservation and use of the institution’s charitable assets will be sustained, providing a prudent financial plan for the maintenance of those funds. I am pleased to present you with this plan on behalf of the physicians and nurses, and the technical, administrative, and support staff of this organization. We have confidence in this medical center, and we ask for your support in voting to approve this plan.
Sincerely,
Paul F. Levy
President and Chief Executive Officer
As I approach my sixth anniversary this week as CEO of BIDMC, I thought you would find it interesting to join me in reviewing two of my earliest communications with the staff of the hospital. When I arrived, the hospital was in dire financial straits, morale had plummeted, and there was an associated exodus of doctors, nurses, patients, and community support.
The Attorney General of Massachusetts, Tom Reilly, had watched the place deteriorate for many years and understandably had little confidence in its ability to survive as an academic medical center. Therefore, to ensure that the beds at the hospital would be available into the future for the good of the public, he was pressuring the Board of Trustees to sell the hospital to a for-profit hospital chain and end its life as an academic medical center. Tom and I had had a long-term mutually respectful and friendly relationship, and I had met with him the previous week and tried to persuade him to give me a short amount of time to turn things around. He agreed, saying, "Because you are personally willing to take this on, I am willing to give you a chance." (By the way, hearing that kind of sentiment from an AG is bit intimidating!) He placed strong and sensible demands on me and the Board to produce a plan, with strict financial milestones, and a commitment to regular reports on our progress.
The staff knew none of this last matter until I arrived and told them.
So the first email I sent was dated Monday, January 07, 2002 at 11:48 AM, roughly four hours after I started work, and was simply entitled "Message for BIDMC". Those of you who have been involved in business turn-arounds will find familiar elements from your own activities. For those of you who have not, this might provide an interesting vicarious experience.
I am honored and pleased to join Beth Israel Deaconess Medical Center as President and Chief Executive Officer, and I look forward to getting to know many of you personally. This is a wonderful institution, representing the best in academic medicine: exemplary patient care, extraordinary research, and fine teaching. However, the place is in serious trouble, and we are going to have to work very hard during the next few months if we are to secure our future as a non-profit academic medical center.
I promise to have an open administration, sharing with you as much information as possible to help you be part of solving the problems of the medical center. Here is where things stand, as of today. Over the last several years, during one of the greatest economic booms in American history, hundreds of millions of dollars of the BIDMC's assets have gone toward paying the operating losses of the hospital. This was money that ordinarily would have been used as the source of funds for new facilities and equipment, for expansion of programs, and as a cushion for hard economic times. For whatever set of reasons, there was a failure to act to stop this financial outflow. We now face our last chance to reverse this problem.
The CareGroup and BIDMC Boards have a fiduciary responsibility to preserve the assets of this charitable organization to serve the public good. The Attorney General of the Commonwealth has the authority and responsibility to review the Boards’ progress in doing so. Because of the current state of the hospital's finances and because of its curious inability to make decisions during the past several years, some observers believe that the best way to preserve those assets is to sell the BIDMC to a for-profit hospital. This would ensure that the beds currently serving the public would continue to do so. In addition, the proceeds of such a sale, after paying off all of the hospital’s debt, would be placed in a community foundation to support healthcare services and programs in the region.
The good news is that my appointment by the BIDMC and CareGroup Boards means that any plans to sell the hospital are, for the time being, off the table. Frankly, I would not have taken the job unless I received that commitment -- because I know we can succeed. My assignment over the next few months is to take steps that will convince the Boards that saving the BIDMC as a non-profit academic medical center is a wise decision. I will be offering a specific plan for doing that, and we will be held accountable to extremely rigorous milestones. If we fall behind -- either because of a lack of will or a lack of ability to implement changes -- the result will be clear.
What specifics steps will we take? I will announce these over the coming days and weeks. As you know, The Hunter Group [note: a management consulting firm] is soon to submit their recommendations to us. Having seen earlier drafts of these recommendations, I can tell you that many of them are sensible and well thought out and way overdue. I am less certain that other recommendations are relevant to us, but all of them will get a thorough review by the administrative and medical leadership of the hospital. In addition, all of you will get a chance to review them and send comments to me, as they will be posted on our website.
Our review will result in detailed implementation plans and milestones for completion. One clear recommendation will be a reduction of staff throughout the hospital. While the exact number is not yet clear, several hundred positions will be eliminated to bring our level of staffing down to what can be supported by our clinical volumes. Layoffs are distasteful, uncomfortable, and scary, but we will carry them out as humanely as possible and treat people with respect and dignity. The many people who remain will be part of a more efficient medical center, and one that will be able to continue to carry out our important mission.
I have not taken this job to be part of a failure. I have taken it because I believe in you, your commitment, and your ability to succeed through this period of adversity. I am looking forward to showing the world what we can accomplish together.
Sincerely,
Paul Levy
A month later, after some very intense work, we put together the Recovery Plan. Here is the introduction to the document which was posted on the hospital's website.
Recovery Plan for the Beth Israel Deaconess Medical Center
February 1 , 2002
To: The Executive and Finance Committees of the Board of Trustees of the Beth Israel
Deaconess Medical Center
From: Paul F. Levy, President and Chief Executive Officer
Over the past several years, the BIDMC has run large, persistent deficits. The medical center has now reached the point where strong, effective, and immediate action is required to reverse this trend. The alternative to these steps will be a noticeable diminution in the quality of care offered by the hospital and a depletion of the assets that are held in the public’s trust. Neither of these results is acceptable.
This plan is a result of a concerted effort on the part of the medical and administrative staff over the past several weeks. It represents a level of teamwork and commitment that is extraordinary and unique in the history of this institution. It is designed to provide immediate financial relief, leading to long-term financial health. However, a financial plan for a hospital like the BIDMC must represent more than a simple reduction in expenses: The trademark of this hospital is its reputation for a warm, caring environment within which patients and their families receive the finest in medical care. Our record on patient satisfaction is extraordinary. If the BIDMC fails to maintain this mission, it will fail. Accordingly, where a decision to implement an activity with potential short-term financial gain conflicts with patient care, we have chosen to err on the side of maintaining patient care. Such choices do not undermine the financial recovery plan: They enhance it.
The healthcare market in Boston is highly competitive, and some have asked whether it is necessary for the BIDMC to exist as an academic medical center. These observers state that the key attribute of the BIDMC is the number of beds it has in service to the public, and that preservation of these beds should be the major goal facing the community. We reject this premise. While retention of beds is an important public health goal, the existence and enhancement of the BIDMC’s role as an academic medical center is also of vital importance to the Boston area medical community and beyond.
Academic medical centers, in general, are regional and national treasures that provide the public with more than high quality health care. They are the cauldrons of innovation in medicine, places in which research flows seamlessly from bench to bedside and back. Physician scientists observe symptoms and trends in patient care, carry hypotheses about the origin and treatment of disease to the laboratory for analysis and testing, and then transport laboratory results back to the clinic. The BIDMC is a national leader in biomedical research. That status is a result of peer reviews of BIDMC research proposals carried out by medical research scientists throughout the country. Scientists at the BIDMC conduct millions of dollars in research funded by the NIH and by foundations like the American Cancer Society, the American Heart Association, and the American Diabetes Association, reflecting the confidence of these organizations in the quality of science carried out here. In total, the BIDMC carried out $140 million in research last year, of which most supported the direct costs of the research and $34 million went to support indirect costs. Many of our scientists are the international leaders in their respective fields and play key roles in setting national research priorities through their roles in study sections and advisory boards. There are direct results from this research in place now throughout the world. Our research enterprise generates new intellectual property on a continuous basis, and this produces sponsored research programs funded by pharmaceutical companies, as well as start-up companies based on our technologies in which the medical center participates. Patients benefit from this research agenda directly when such research is applied but also by the fact that the existence of this effort encourages the very best doctors to practice at the BIDMC.
Academic medical centers are also the training ground for future physicians. As in the case of research, the interplay between education and patient care is extraordinarily important. The opportunity to work with and train an outstanding group of medical students and residents is a major attraction that draws the highest quality staff physicians to a world-class medical center such as BIDMC. Practicing physicians will also tell you that their involvement in training medical students and residents requires those physicians to maintain their professional edge, keeping current with the latest advances in clinical care. Trainees at all levels will report that their experience in the halls of the hospital is critical to their education as doctors. This phenomenon has been recognized by the federal government by its funding of medical residents through the Medicare program. At Beth Israel Deaconess, we receive approximately $53 million annually for graduate medical education (the training of residents and subspecialty fellows).
The BIDMC is a leader in medical education at all levels. Our physicians provide approximately one-third of the clinical instruction of Harvard Medical School students, offering training in the following fields: internal medicine, surgery, obstetrics and gynecology, neurology, psychiatry, orthopedics, radiology, pathology, anesthesiology, emergency medicine, dermatology, radiation oncology, and neonatology. At the residency level, the BIDMC offers training in all of the above fields to an annual incoming residency class of approximately 125 men and women (for a total complement of approximately 450 residents over their several years of training). An additional 160 physicians receive more advanced subspecialty training in a wide variety of disciplines.
Does the BIDMC need to exist and carry out these functions, or should it devolve into a community hospital, offering a range of medical specialties to the public? This is a plan that has been put forth by some observers. We think it is shortsighted. While it could be argued that the BIDMC’s scientists and teachers could go elsewhere, such an argument leads to a reductio ad absurdum result. The same could be said for every academic medical center. How are we to choose which organization should live or die?
We are realistic enough to know that, in today’s environment, the answer will be guided by the underlying finances of the institution. Unless the BIDMC is able to maintain its clinical programs in a manner consistent with fiscal responsibility, it will not be able to generate sufficient support to remain as an academic medical center. This plan is a blueprint that will support that result. The issue for the BIDMC is not so much whether it should remain an academic medical center: Rather, we will need to decide what mix of clinical care, research, and teaching can be supported. To date, the financial systems and institutional structures of the BIDMC have foreclosed making those decisions. As a result of changes we will make, those choices will be apparent, and decisions will be made about the programmatic priorities for the hospital.
The recovery plan is guided in great measure by the recommendations of The Hunter Group ("THG"). The report prepared by THG has been made available to every employee in the medical center, and we have received hundreds of suggestions and comments regarding the implementation of the measures contained therein. Every one of these suggestions has been considered by senior management. There is much that is good in THG report. It sharpens the focus of our efforts, offering a range of specific financial targets we must achieve. Many of the recommendations of THG are correct, and in fact reinforce those of previous consulting firms. We embrace those recommendations wholeheartedly and have already started implementing many of them. Other THG recommendations are correct insofar as their purpose and goal, but need modification with regard to implementation. In this proposed recovery plan, we commit to achieving the financial results of such measures set forth by THG, but we promulgate a more realistic plan for achieving them. A small number of THG recommendations are unsupported and impractical and have been dismissed. Finally, we offer a set of our own recommendations that were not proposed by THG.
Our recovery plan has a clear financial target. Progress towards that target will be presented to the Board, and it is measurable at every step along the way. We have considered THG’s recommendation that our approach should be to reach a goal of a 3% margin on clinical care within the next two-and-a-half years. This is not realistic given our plan to maintain high quality patient care and, if achieved, would place the BIDMC in a range of performance seldom achieved by academic medical centers. It also would place an undue strain on an institution that will already face massive organizational challenges.
Inherent in our target is a need to stem the "run rate", the degree to which hospital operations are depleting the unrestricted assets of the corporation. We must and will demonstrate a dramatic reduction in the run rate throughout the remaining months of fiscal year 2002. Clear targets for fiscal year 2003 and 2004 are also presented, leading to a break-even result in fiscal year 2004. In the interim, we believe it is appropriate to budget a certain level of operational support from the endowment for three purposes: to compensate for the institution’s past lethargy in making operational improvements; to support the level of research and teaching that are critical to the overall success of this academic medical center; and to serve as a venture fund to finance strategic initiatives that will bring longer term revenue enhancement and quality improvement in this hospital.
On the revenue side of the ledger, we project no increase in patient volumes for fiscal year 2002, but we do commit to a modest increase in such volumes in 2003 and 2004. This contrasts with THG report, which has no expectations of such revenue growth. This commitment is offered by the chiefs and the medical staff directly. It reflects the substantial financial investment being made to recruit a number of the excellent surgeons to this hospital. It relies, too, on increasing physician productivity, particularly with regard to ambulatory care. Finally, it rests in great measure on enhancing relationships with referring physicians throughout the Boston area. The physicians are directly accountable for the success of this recovery plan, and they are willing and ready to stand by that commitment.
Also, on the revenue side, we show income from the rental of real estate. This measure reflects the surfeit of space in the medical center, relative to the size of its clinical and academic functions. That the amount included in our rental projections is achievable reflects inquiries and commitments made during the last several weeks, as well as our own estimate of future tenancies. In choosing to rent space, we will limit ourselves to tenants which have a strategic synergy with the medical center -- organizations which conduct medical research and clinical care that is consistent with our mission and with which we are likely to want to maintain a close relationship over the coming years.
How can the Board best measure our progress in carrying out this plan? Of course, we will provide month-to-month figures on patient volume and financial performance. The advantage of such real-time data is that it offers the potential to track early indicators, but the disadvantage is that any given month’s figures can also cause misleading hope or discouragement. Obviously, it is only the trend over several months that is meaningful.
The difficulty of measuring the success of our program is inherent in the nature of this medical center. The preponderance of our costs are fixed, but the preponderance of our revenues are variable. Even a small shift in patient volumes can cause large swings in the month-to-month bottom line. This problem is aggravated by the fact that the hospital has and will invest large sums of money in the potential for future growth. We have large commitments to recruitments in surgery and anesthesia, for example. Likewise, our physical plant and equipment is sized for a larger patient volume than currently exits.
If we were in the manufacturing business, we would shed workers, close down divisions, and sell assets in the face of a downturn in volume – in essence, adjusting the fixed cost base to be commensurate with a reduction in revenue. Here, our investment commitments are not so variable or fungible. Our staff is our key resource. We cannot increase and decrease the numbers of doctors, nurses, and technical staff every quarter in response to volume changes. Neither can we buy and sell property and reconfigure operating rooms and other patients facilities every several months.
If we were financially healthy, we could deal with these variations by drawing on our "bank account" of unrestricted reserves, knowing that those reserves would be replenished in good times. Here, we have done this for a number of years but without replacing those funds, thus severely restricting the amount available for future use. As THG notes, time is running out if we intend to use those reserves in that manner for much longer. We are proposing a dramatic reduction in this practice, but, as noted above, some continued drawdown of these funds should be expected over the next two-and-a-half years as we pay off the investment costs needed to bring about a longer term level of sustainable patient volumes.
The major portion of this submission is our plan. In that section, we present our major initiatives in Quality of Patient Care; Revenue and Volume Growth; Expense Management; and Strategic Direction. We also provide a narrative comparison with THG’s recommendations in each area.
Our report also contains a series of charts presenting the financial summary for BIDMC that is our target for fiscal years 2002, 2003, 2004. We show projected overall financial results for each year, along with a month-by-month projection of the run rate during this period. These figures are presented alongside those offered by THG. Accompanying these figures is a summary of the performance monitoring tools and metrics that will be in place to measure our success in meeting these financial targets.
Finally, for ease of review, we present a chart in which we present each of the 200-plus THG recommendations and its projected effect in each of the three fiscal years. In the same chart, there is a narrative indicating the degree to which we accept the recommendation along with the financial target associated with our plan for each of the three fiscal years.
Before closing, I must address the concern that has been raised by THG and by other observers: Does the medical center have the ability and the will to carry out these recommendations? Many of the THG recommendations have been offered by previous consultants and yet were not carried out. Why is the situation different now?
Let us briefly review the reasons for the institution’s past failure. Recall that BIDMC had previously engaged Ernst and Young, Deloitte and Touche Consulting, and CSC as consultants to offer advice on achieving financial improvements. These firms independently developed many good ideas which significantly overlapped each other; so the turnaround plans did not fail because of a lack of ideas. While certain aspects of each plan may not have been totally achievable, the majority of the initiatives could have been accomplished.
One of the problems encountered was that the financial target that was established was too small. For example, the 1999 Genesis project stated the budget problem as $52 million per year. In the course of that effort, opportunities were identified totaling $95 million, of which management agreed to implement $75 million, of which about $59 million was actually achieved. However, the projected budget problem increased from $52 million to approximately $100 million during that period.
Another problem was that of unrealistic expectations. The 2000-2001 turnaround plan placed significant reliance on the establishment of a profitable partnership with a pharmaceutical or bio-tech company. The confidence expressed by senior management in this highly uncertain venture was not supported by evidence from outside the organization. In addition, knowledgeable people within the medical center who doubted its efficacy were treated as nay-sayers, and their voices were stilled or discounted.
A third problem was a failure to mesh broad views of how things would improve with the process of change within the organization. The plan developed in 2000 was announced before determining if certain key elements of its design could be accomplished. This conceptual "model" emerged as a "plan" before details could be developed, and the plan was immediately challenged at the detail level in a confrontational manner. Rather than a rational evaluation of the concepts, details were challenged: Decisions were then made in response to the confrontations. Senior management underestimated the reaction to the plan and was distracted by internal and external politics and publicity. As a result, it was difficult to address the very complex implementation and management issues inherent in the change process.
Significantly, a sense of urgency in the medical center had not been established prior to the announcement of this or any previous plan. While BIDMC senior leaders understood the urgency, they overestimated how successful they had been in communicating that sense and establishing it more broadly in the hospital. In part, too, many physicians did not accept the urgency because of a belief that a merger with Partners Healthcare system could occur; that a break-up of CareGroup would solve the problems of the BIDMC; or that Harvard Medical School and Harvard University would act as saviors.
During this last effort, a clear vision for the BIDMC was not accepted. The result was a failure to develop a guiding coalition of key physicians, managers, and Board members, resulting in an inability to remove obstacles to a new vision. This led to a failure to put the needs of the organization ahead of the individual needs and desires of its many internal constituencies. Suggestions that really could have made a difference were not accepted.
Finally, the last turnaround plan had a strong dependence on increasing clinical volumes, especially of high level tertiary and quaternary care. However, the lack of confidence on the part of specialty physicians in the future of the hospital led to faculty turnover that increased the volume gap. Meanwhile, remaining physicians did not fundamentally alter their practice to spend more time on clinical activities.
How is the current situation different? First and foremost, there is now a clear understanding on the part of the medical and managerial staff that the "platform is burning." The decision by the CareGroup Board of Directors to consider seriously the sale of the hospital is now widely known and has provided strong motivation to all parties to work on solving the institution’s financial problems. The involvement of the Attorney General of the Commonwealth, given his statutory responsibility with regard to public charities, underscores the fact that the Board of Directors will be held accountable for its fiduciary responsibilities, lending even greater credibility to that potential threat.
Second, we have shared with the entire hospital the contents of the Hunter report. This independent analysis offers a sobering conclusion about the future of the medical center, absent effective action. It offers detailed proposals for action within every department. It provides us with the tools to establish a realistic financial target, based on appropriate estimates of inflation in personnel and supply costs. It also provides objective criteria by which corrective actions can be judged. Broad-based knowledge of these aspects is key to success, and the report has received over 100,000 hits on the company intranet, and there have been thousands downloads of all or a portion of it. This is an unprecedented distribution of a management consulting report in an academic medical center. (We will follow up with a similar distribution of this plan.)
Third, we have created an environment in which suggestions and contributions from the broad base of physicians and employees are welcomed, solicited, and evaluated. Even if all of these ideas are not adopted, the fact that we have asked is an important aspect of building a constituency for the final decisions. We have created a culture that will avoid failure because the needs of the organization are clearly considered along with the needs and desires of individuals. Suggestions that really can make a difference will be accepted.
This is not to say that the path is easy or straightforward. While the physician leadership and individual physicians care deeply about the future of the BIDMC and are actively engaged in this effort, the day-to-day decisions of those physicians will depend on the creation of institutional incentives (both between the hospital and HMFP and within HMFP) that clearly align the financial and operational incentives of individual faculty practices and the hospital. Likewise, nurses and technical workers on whom we rely so much for the care of patients will need to make adjustments in the way they carry out their work, while maintaining the overall quality of care. Administrative staff will have to focus on the fact that they are part of the overhead cost in an organization the core mission of which is to serve patients and families, and so they will need to be engaged in continuous improvement and searches for greater efficiency.
The foundation for these efforts, though, has been poured. The spirit of the hospital is strong, and the commitment of those working here is as intense as ever. In summary, we offer a financial plan that is real and achievable, but we recognize the tremendous effort that will be required to achieve it. The plan satisfies the fiduciary responsibilities of this Board of Trustees. First and foremost, it promises our patients and their families that the quality of care they receive at this hospital will meet the high standards they expect. Equally important, it ensures that the public’s trust with regard to the preservation and use of the institution’s charitable assets will be sustained, providing a prudent financial plan for the maintenance of those funds. I am pleased to present you with this plan on behalf of the physicians and nurses, and the technical, administrative, and support staff of this organization. We have confidence in this medical center, and we ask for your support in voting to approve this plan.
Sincerely,
Paul F. Levy
President and Chief Executive Officer
So that's how it all started. So far, so good, as a result of thousands of people both within the hospital and from the community with a shared set of values working together to support an incredibly worthwhile mission. Let's see what the coming years bring.
Wednesday, January 02, 2008
PatientSite comes through again
I know I have written about PatientSite before, but I wanted to share this recent note from a patient. I am sorry if it seems too self-congratulatory for me to do this, but when you get a reaction like this, it is very satisfying. You can check out the demo here.
Just wanted to let you know that the patientsite.org program is FANTASTIC!! I recently had an Echo and Stress test (due to chest pains and shortness of breath) which came out normal, but I could get the results when it was convenient for me, without bothering my very busy physician -- especially since the results were normal. Of course, had they been abnormal he would have been available to discuss the results, but to be able to access my information and get the details I needed so quickly and simply is just amazing (and efficient). Congratulations to you and the whole IT team for a very patient-centered program.
Just wanted to let you know that the patientsite.org program is FANTASTIC!! I recently had an Echo and Stress test (due to chest pains and shortness of breath) which came out normal, but I could get the results when it was convenient for me, without bothering my very busy physician -- especially since the results were normal. Of course, had they been abnormal he would have been available to discuss the results, but to be able to access my information and get the details I needed so quickly and simply is just amazing (and efficient). Congratulations to you and the whole IT team for a very patient-centered program.
Bravo Brigham!
Liz Kowalczyk writes in the Boston Globe today about plans by Brigham and Women's Hospital to improve access to families of patients in its intensive care units. The Brigham is just completing a new building, and they have designed the ICU rooms to have sufficient space and amenities to permit family members to stay overnight. Here is the significant excerpt:
The rooms will be as big as 350 square feet - about double the size of the hospital's current rooms - and patients will be able to designate a relative or friend to stay with them each night, basically living alongside them in the room.
Doctors and nurses will encourage family members to help provide basic care, such as bathing and changing bandages, and allow designated individuals to remain in the room for most procedures, including removal of chest tubes, insertion of intravenous lines, and even resuscitations.
This is really an excellent step, and the Brigham deserves credit for including the possibility in the design of the new space -- but mainly for adopting medical rules and regulations that encourage this type of care.
In this regard, we are behind at BIDMC. As noted by a recent patient in a letter to me: "The ICU staff generally still sees family as outside of the direct care system.... The first night in the ICU was really awful, in that the visiting hours were strictly imposed, and we were allowed 2 people to visit her for five minutes every other hour. The nurse would look up at the clock when we entered, a kind of visual cue that she was counting. I’d strongly encourage (maybe, beg) for you to reconsider this policy in the ICU and throughout. I was told that the policy was in place for several reasons, but that the staff would never keep a family and a dying patient apart. I agree but think you are missing some wonderful energy and resources by placing limits in non-terminal situations."
So thanks to the Brigham for setting a great example. We are currently reviewing our own regulations to figure out what changes we should make. Likewise, in designing new ICUs and other rooms, we will be sure to make this a physical possibility. (By the way, the decision by the Brigham to expand the normal size of a room clearly adds costs. I think many would agree that this is money well spent, but I wonder if any of the insurers out there reading this would want to comment on how they feel about paying for this.)
The rooms will be as big as 350 square feet - about double the size of the hospital's current rooms - and patients will be able to designate a relative or friend to stay with them each night, basically living alongside them in the room.
Doctors and nurses will encourage family members to help provide basic care, such as bathing and changing bandages, and allow designated individuals to remain in the room for most procedures, including removal of chest tubes, insertion of intravenous lines, and even resuscitations.
This is really an excellent step, and the Brigham deserves credit for including the possibility in the design of the new space -- but mainly for adopting medical rules and regulations that encourage this type of care.
In this regard, we are behind at BIDMC. As noted by a recent patient in a letter to me: "The ICU staff generally still sees family as outside of the direct care system.... The first night in the ICU was really awful, in that the visiting hours were strictly imposed, and we were allowed 2 people to visit her for five minutes every other hour. The nurse would look up at the clock when we entered, a kind of visual cue that she was counting. I’d strongly encourage (maybe, beg) for you to reconsider this policy in the ICU and throughout. I was told that the policy was in place for several reasons, but that the staff would never keep a family and a dying patient apart. I agree but think you are missing some wonderful energy and resources by placing limits in non-terminal situations."
So thanks to the Brigham for setting a great example. We are currently reviewing our own regulations to figure out what changes we should make. Likewise, in designing new ICUs and other rooms, we will be sure to make this a physical possibility. (By the way, the decision by the Brigham to expand the normal size of a room clearly adds costs. I think many would agree that this is money well spent, but I wonder if any of the insurers out there reading this would want to comment on how they feel about paying for this.)
First 2008 baby in Boston
A friendly competition among hospitals each year. Let's do our best to make it a good year for all the new arrivals!
Tuesday, January 01, 2008
Dear PHC, Please vote yes on mini clinics
Way back in May, I wrote in support of storefront clinics of the type proposed at that time by the company that owns CVS pharmacies. Since then, there has been a lot of back-and-forth on the issue. Significantly, the state Department of Public Health looked into the issue and received lots of comments as to how best to proceed.
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