Getting transparency right

This is about transparency, when it is useful and when it is not. The term is now an established part of the health care lexicon, but there is little substantive discussion about how it is being used.

As I said in an article in Business Week over three years ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Now, there rises an additional misconception. The perversion of the transparency concept that has evolved rides on the desire of CMS and private insurance companies to use publicly published outcome data to financially reward or penalize hospitals. As expected, this is raising hackles. The complaints often heard from hospitals are ones we have discussed before: "The data are wrong." "Our patients are sicker."

I am not going to accept those complaints, but I am going to suggest that the usual government mandates for transparency of data provide little basis for the kind of process improvement we need in hospitals. What's wrong with these mandates?

For one thing, the data are old. While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror. The principles of Lean process improvement and other such systems suggest that real time "visual cues" of how the organization is doing are essential. Why? Because that kind of data is indicative of the state of the organization right now, not what existed months or years ago. Such data are collected in hospitals on a current basis. If their main purpose is to support process improvement, they do not need external validation or auditing to be made transparent in real time.

For another thing, the choice of data in the government's approach to transparency is externally imposed. Process improvement occurs when the people who do the work jointly decide what areas of change are important. We need to trust that the clinicians and administrators in hospitals, working with their patients and boards of trustees, are better able to decide on quality and safety priorities than the government or its agents. We want the hospitals to be transparent about the metrics they choose, knowing that their doctors, nurses, other staff will value the results highly and act on them.

Finally, the payers' approach to transparency creates attention on meeting certain outcomes, rather than stimulating a desire to design and implement a comprehensive structure to achieve better outcomes. A wise colleague said recently, "Obsession with outcome without obsession with structure will fail."

Captain Sullenberger talked about this in another respect: "A checklist alone is not sufficient. What makes it effective are the attitude, behavior, and teamwork that goes along with the use of it."

In summary, transparency of data alone is not sufficient. What makes it powerful in establishing creative tension in an organization are: The currency of the data; the fact that the metrics being made transparent have been chosen by those involved in the process improvement efforts; and the fact that the transparent outcomes are supported by a structure of ongoing process improvement.

As we have seen by examples on this blog, those hospitals that have been most effective in the challenge of process improvement have not done so because a government agency is making their clinical outcomes transparent. They have done so because the administrative and clinical leadership, strongly supported and encouraged by boards of trustees, have made it clear that this kind of effort is a top priority. More and more places each month have discovered the importance of transparency in supporting their efforts. How this takes place will be specific to each hospital, but it is clear that, to be effective and sustainable, change must come from within.

Transparency, a reprise

The Institute for Healthcare Improvement offers an occasional 2.5 day course for hospital senior leadership teams, which they call their Executive Quality Academy. They admit hospital teams to develop action plans to lead quality improvements in their organizations. (The group above is from Winchester Hospital, a very fine community hospital in Eastern Massachusetts. There were also folks from Stanly Regional Medical Center in North Carolina, the Indian Health Service's Red Lake Hospital in Minnesota and North Dakota, and several hospitals in Florida.) Dr Vinod Sahney, one of the faculty members, asked me to come by this last week and talk about the role of transparency in this kind of effort.

As I did, it occurred to me that recent arrivals to this blog might not be familiar with how I have used it to experiment with reporting of clinical results, with the hope of helping to hold our organization accountable for meeting quality improvement metrics. As I said in an article in Business Week about one year ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Rather than repeating my IHI talk here (boring!), I am just going to list below some key posts to which I referred during my session. (Who needs PowerPoint if you have a website!) If you are interested, you can follow them through and get an idea of the journey we have taken during the past two years. As always, I welcome comments on these, but I am also seeking comments from those hospitals that have also tried this approach, so we can learn from your experiences, too.

These things happen -- a description of the point of view, all to often found in hospitals, that a certain level of harm that occurs to patients is "just the way things are."

We saved one person's life -- one of series of posts on our effort to eliminate (yes, eliminate) central line infections.

Teamwork wins against VAP -- one of a similar series on our efforts to eliminate ventilator associated pneumonia.

Aspirations for BIDMC and BID~Needham -- the story of how our Boards established an overall goal for these two hospitals of eliminating preventable harm over the next four years.

Source material -- Detailed background on the material behind the Boards' votes.

Next stage of transparency -- A link to our website documenting our progress, quarter by quarter, towards the goal to eliminate preventable harm.

The message you hope never to send -- How we used transparency to learn from one of the most egregious errors that can occur at a hospital, a wrong-side surgery.

The moral component to transparency

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

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

Here we go. Act 2.

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

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

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

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

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

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

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

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

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

Re today’s Globe:

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

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

Specifically we are including in this:

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

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

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

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

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

A prominent attorney in town wrote a colleague, saying:

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

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

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

A knowledgeable industry observer in Boston said:

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

My colleague Bob Wachter, at UCSF, said:

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

A former state legislator said:

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

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

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

A local search firm consultant and former colleague wrote:

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

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

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

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

One of our urologists wrote:

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

One of our Nurse Practioners in Hematology/Oncology wrote:

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

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

A member of the BIDMC Board of Directors wrote:

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

One of our young nurses wrote:

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

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

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

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

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

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

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

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

I love you,
Becca

Comments to Division of Insurance

The MA Division of Insurance is conducting a review of why health care premiums in the state continue to rise. Some observers complained about the lack of participation by providers in the public hearings on this matter, ignoring the fact that the Division had provided very little advance notice of the specific dates.

Meanwhile, a number of us in the provider community have submitted written testimony. In the absence of news coverage of those comments, I offer mine for your review and thoughts. As you will note, it is within the power of the state government to take steps right now that could help "bend the cost curve," but it has been unwilling to date to exercise that authority.

Mr. Kevin Beagan
Deputy Commissioner
Division of Insurance
One South Station
Boston, MA 02110

Dear Mr. Beagan:

On behalf of our physicians, nurses, volunteer Boards of Directors and Trustees, and the entire Beth Israel Deaconess Medical Center (BIDMC) community, I want to thank you for the opportunity to submit written comments to the Division. I understand that your goal is to examine the reasons for significant increases in small business health insurance premiums and to explore how we -- policy makers, hospitals, health insurers, physician practices, community health centers, employers, employees, consumers and others -- can work together to address these rising premiums.

I am grateful to the Division for posing this question directly. Our ability to address these issues will have profound implications for the Commonwealth’s job growth and economic future as well as the sustainability of providing universal access to health care coverage in Massachusetts.

We have been pleased over the last year to have worked with many stakeholders on key components of this effort, including our hospital colleagues in Massachusetts and throughout the country, the Massachusetts Special Commission on the Health Care Payment System, policy makers, Legislative leaders, and others.

I have four major sets of recommendations and observations to share with you, based on the eight years I have served as President and Chief Executive Officer of BIDMC:

Make Quality and Transparency Count. There is simply no substitute for transparency of data on the quality and safety of patient care. Thus far, this information is of limited use by consumers and purchasers, although that is likely to change over time. In the meantime, and perhaps more importantly, the value of transparency is as a management and process improvement tool. As I said in an article in Business Week in September of 2007:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

At BIDMC, we have been publishing quality information for several years. During this same period, we have steadily improved our performance. We know that we are saving hundreds of lives and millions of dollars in health care costs as a result of the quality and safety initiatives we have carried out. An indication of our institutional commitment to this direction is that the governing bodies of our hospital -- the Board of Directors and Board of Trustees -- took audacious votes last year to eliminate all preventable harm at BIDMC by 2012 and to be transparent about our progress and results. This information is published quarterly on our website at www.bidmc.org.

Improve Public Payer Reimbursement and Rationalize Payment for all Health Care Services. Levels of public reimbursement are a contributing factor to higher-than-necessary private insurance premiums. Medicaid, Medicare, and the Health Safety Net Trust Fund reimburse hospitals – on average -- at significantly below the cost of providing care. These payment inequities are particularly acute for services to some of our most vulnerable patients, such as for inpatient mental health care. Because of this, we are forced to identify alternative revenue sources to cover our operating costs. One such source is our reimbursement from private insurers. The overall reimbursement we receive from private health insurers ultimately subsidizes our losses from public payer contracts that fail to cover our costs. State budget reductions for academic medical centers over the last two fiscal years have had a sustained, significant negative impact on our fiscal health. But these two years have been different only in degree, not in direction. For years, public payer losses have also damaged our ability to keep up with the capital investments needed to maintain our facilities on an annual and long-term basis.

In addition, for many key services that are central to our non-profit mission, private health insurer reimbursement also fails to cover our costs. This means we are forced to invest in higher cost services that command higher reimbursements and cross-subsidize services for which we are drastically underpaid. The Division should work with health insurers and other stakeholders on strategies to improve public payer reimbursement, rationalize payment for health care services, and eliminate the need for cross-subsidization.

Correct Market Dysfunctions. We have to acknowledge that the manner in which reimbursement rates are established in this state is not related to the quality of medical service provided. Instead, market power seems to be the predominant factor in the rate-setting environment. Thus, we have the odd result that, for example, the reimbursement rate for the very same colonoscopy performed on exactly the same type of patient will vary by large percentages depending in which contracting network a doctor happens to be situated. I will tell you frankly that BIDMC and our physician contracting organization, BIDPO, is sometimes a beneficiary of this process. At other times, we are put at a competitive disadvantage. In both cases, this is a result counter to sound public policy.

There are two solutions to this problem. The first would be to return to a rate-setting environment, in which the Commonwealth would establish the reimbursement rates for each insurance company and each provider organization. I personally would not have a problem with such an approach, in that health care can viewed as a “utility-like” function, in which reliance on competitive forces is unlikely to produce economic efficiency and equity.

Short of rate-setting, I believe the Commonwealth should use its existing authority to make reimbursement contracts public. Allowing sunshine to reach the current reimbursement arrangements would provide moral and political pressure from subscribers, public officials, and the public on the insurance companies to equalize payments across provider groups. I believe this would result in rate-setting methodologies that are more tied to the quality of service provided.

Embrace Innovation in Health Care Delivery with Accountability to Consumers. At BIDMC, we recently teamed up with the state’s largest physician group practice, Atrius Health, to establish a new model for health care delivery in the Commonwealth. We are using shared electronic medical records to improve our efforts to provide the right care at the right time in the appropriate setting. We have also embarked on a robust agenda for quality improvement and cost-efficiency strategies. Our collaboration will be built around a strong emphasis on primary care, and a continuum of care from the ambulatory setting to the hospital and beyond. Among our strategies:

Putting primary care at the center of patient’s care;
Ensuring that physicians work together as a team with nurses, technicians and other allied health professionals;
Enhancing and further integrating electronic medical records;
Advancing health equity and ensuring a diverse, culturally competent interdisciplinary workforce;
Preventing and reducing medical errors and being transparent about results;
Improving the efficiency of health care delivery by continuous process improvement as exemplified by the LEAN methodology; and
Empowering patient involvement in the design of the health care delivery system through advisory councils, secret shoppers, patient satisfaction surveys, and other mechanisms.

We are confident that these innovative strategies – put into practice – will have a meaningful impact on quality, access and the cost of health care in Massachusetts.

I hope that the foregoing comments are helpful, and I would be glad to discuss these with you in the future.

Very truly yours,

Paul F. Levy

Economists running amuck

Economists are so embedded in their training with the concept of ceteris paribus -- "all other things held equal" -- that their policy prescriptions often go awry. Here are two recent examples:

First, in the March 10, 2011 issue of the New England Journal of Medicine, David Cutler and Leemore Dafney argue against transparency of pricing in the health care sector.

The rationale for price transparency is compelling. Without it, how can consumers choose the most efficient providers of care? But though textbook economics argues for access to meaningful information, it does not argue for access to all information. In particular, the wrong kind of transparency could actually harm patients, rather than help them.

Applying the sunshine rule in the provider–payer context, however, could have the opposite of the intended effect: it could actually raise prices charged to patients.

[T]he sunshine policy would create a perverse incentive for the hospital to raise prices (on average), and as a result its rivals could do the same. This adverse effect of price transparency would arise only in cases in which the buyer or supplier in question had some leverage (market power), but such leverage is fairly common in health care settings, including many local hospital markets.

What's the flaw here? In markets like Eastern Massachusetts, there is a dominant provider which uses its market power to garner above average prices from the insurance companies in its service area. That provider, in turn, can use those revenues to offer higher salaries than its competitors, drawing doctors into its orbit. It also has more resources to expand its ambulatory care facilities. Both steps serve to further expand its market power.

Then, that expanded referral base sends still more patients to the flagship tertiary hospitals. Those hospitals and the doctors therein are paid more than other hospitals in that area.

In short, the higher rates obtained in secret negotiations serve over time to increase the overall cost of care in such a region. In the absence of state rate-setting authority, a powerful way to put a break on this practice is to publish the rates paid by each insurer to each hospital and physician group. With no documented difference in the quality of care among providers, the publicity therein created creates sufficient moral authority for insurers to show some backbone in subsequent negotiations. It also creates the rationale for limited network insurance products, in which subscribers pay different premiums and co-pays for the option of using lower cost providers.

Would you like proof? Until the Attorney General published the relative payments received in the Massachusetts market, the market-power driven system ruled in this state. It was only after her office demonstrated the inflationary effect of such a system that moves to equalize rates began in earnest and tiered products took hold.

Contrary to the point raised by Cutler and Dafney, the point of price transparency is not mainly to offer individual consumers information about provider choice. After all, the vast majority of people go to hospitals and specialists recommended by their primary care doctor. Price transparency creates general awareness among providers, insurers, and large business purchasers of the dynamics of the marketplace. This providers an umbrella for effective change.

Second, in the New York Times, Paul Krugman today gets it wrong when he asserts that "Medicare Saves Money".

The idea of Medicare as a money-saving program may seem hard to grasp. After all, hasn’t Medicare spending risen dramatically over time? Yes, it has: adjusting for overall inflation, Medicare spending per beneficiary rose more than 400 percent from 1969 to 2009.

But inflation-adjusted premiums on private health insurance rose more than 700 percent over the same period. So while it’s true that Medicare has done an inadequate job of controlling costs, the private sector has done much worse.

And then there’s the international evidence. The United States has the most privatized health care system in the advanced world; it also has, by far, the most expensive care, without gaining any clear advantage in quality for all that spending. Health is one area in which the public sector consistently does a better job than the private sector at controlling costs.

Here's where Mr. Krugman is wrong. The Medicare rates paid to doctors and hospitals are set by government fiat. They are based on Congressional appropriations, political decisions resulting from the give and take of the legislative process. Ditto for Medicaid rates set by the states. They have little or no relationship to the cost of providing service to patients. When there is a shortfall in Medicare and Medicaid revenues, the difference is made up by the rates paid by private insurers.

He is also wrong in comparing the US to other countries and asserting that the difference in costs is based on the difference between private and public systems. That difference is based on a variety of factors, of which public versus private is but one. For example, many national systems rightfully put a greater emphasis on primary care than the US. This is clearly cost-effective. But, it is the Medicare-approved pricing system that overpays specialists relative to primary care doctors and other cognitive specialists -- not only for Medicare, but for private insurers, too.

Many other countries, too, provide free medical education to prospective doctors, reducing the salary needs of those professionals. Some countries, like Italy, allow virtually anyone to go to medical school, creating a surfeit of doctors, whose wages are then bid down.

Finally, of course, the national budgets for health care in public systems are -- like Medicare -- the result of governmental fiat that have had little or no relationship to the demand for health care services or the underlying cost of such services. As I have noted,

[T]his appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources.

When the government doesn't want to pay for these services, what happens? A parallel, private system of doctors and insurance companies emerges.

But even there, nationalized system in other countries are starting to see US-like cost pressures as demographic and political trends push them to offer greater levels of specialized tertiary care and facilities. The systems are starting to converge:

I predict, though, that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

So, Mr. Krugman, ceteris paribus doesn't apply here. Nothing else is held equal when it comes to comparing health care systems.

(By the way, I agree with his conclusion that raising the Medicare eligibility age from 65 to 67 does not make sense, but that's for other reasons.)

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.

Empathy without action is empty

One of the most compelling videos in recent years is the one produced by the Cleveland Clinic entitled "Empathy: The Human Connection to Patient Care." Since its publication in February of 2013, it has been viewed by over 2 million people. If you don't shed a tear while watching it, I'd be surprised. It reflected very well on the image of the Clinic.

Less covered was the fact that before, during, and after this time, the Clinic was cited multiple times by CMS for flaws in patient safety oversight.  Joe Carlson at Modern Healthcare documented this in a story last June.

A three-month Modern Healthcare analysis of hundreds of pages of federal inspection reports reveals the 1,268-bed hospital spent 19 months on “termination track” with Medicare between 2010 and 2013 as a result of more than a dozen inspections and follow-up visits triggered by patient complaints. 

The Cleveland Clinic, with 36 deficiency complaints, ranked 20th on the list of hospitals with deficiencies stemming from patient complaints.  

How can these two aspects of the same hospital persist side by side?  I think we have to understand that there is often a corporate separation between the public affairs side of the house and the clinical governance side of the house in the hospital world.  The former takes money and creative thought.  The latter takes an unceasing commitment to clinical process improvement and especially to transparency.

This was noted by one of patients who complained, retired Air Force Col. David Antoon:

Hospital officials refused to show the inspectors all of the notes in Antoon's complaint file, and the doctor who claimed to have done the procedure declined to talk to surveyors about how the hospital handled the case, CMS inspection reports show.

Antoon, a commercial 747 pilot in civilian life until the operation left him incontinent, is baffled that medicine has no organization like the National Transportation Safety Board to address safety failures. “You cannot keep things concealed in aviation,” he said. But in healthcare, “They're just gathering data points from patient complaints. And every data point is a damaged life or a death.”

The power of transparency has been asserted and documented time after time.  Most recently, the National Patient Safety Foundation made the case that true transparency--between clinicians and patients; among clinicians within an organization; between organizations; and between organizations and the public--"will result in improved outcomes, fewer medical errors, more satisfied patients, and lowered costs of care."  The Children’s Hospitals’ Solutions for Patient Safety (SPS) Network, which originated in Ohio, is a clear example of these principles.

We also found this to be the case at my former hospital, where in 2008 our Board voted to be forthright about the number and types of cases that resulted in preventable harm to our patients.  At the time I noted:

We will be publicizing our progress towards these goals [of eliminating preventable harm] 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.
 
We even used transparency to learn from one of the most egregious errors that can occur at a hospital, a wrong-side surgery. 

Years later, the importance of this approach--especially for the future leaders of the profession--was reaffirmed in a note I received from one of our residents (emphasis added): 

For me, a trainee at the time, the most important effect was that [transparency] underlined a shared sense of mission and purpose around quality improvement. The reporting didn't have a big direct effect on my practice--I just tried to learn how to put in central lines the right way, while my elders had already defined what the "right way" was. The indirect effect was as part of a sense of purpose, though.

The absence of a sense of purpose of this kind is toxic. For instance, if you have an advertising campaign that emphasizes our kindness or humanity, but we have no policies or practices that distinguish our kindness or goodness from anyone else's, it may be persuasive to our market as a branding tactic, but it's actively alienating to those of us who work within this system.

In short, empathy without action is empty. The resident concluded:

Conversely, if we walk the walk more than talk the talk, it's inspiring. Posting the data probably influenced very few patients one way or another--but it definitely made many of us feel like we were walking the walk. 

Borrowing safety ideas in the Netherlands

I just attended and presented at a conference at Jeroen Bosch Hospital in 's-Hertogenbosch (den Bosch), in the Netherlands, entitled "Quality and Transparency in Care and Training." It was held on the occasion of the opening of an entirely new hospital, following a merger with two other hospitals in the city (Bosch Medicentrum and the Carolus Hospitals). Hospital administrators and clinicians from throughout the country attended.

Our MC for the day was Jozein Bensing, professor of health psychology at the University of Utrecht. Relative to today's topic, she is most known for a paper she published a few years ago documenting that 1700 people per year unnecessarily die in Dutch health care facilities. This report gave substantial impetus to improvements in patient safety in the country's hospitals.

Jozein chairs the quality and safety committee of Jeroen Bosch's supervisory board (the equivalent of the board of trustees of a US hospital.) She said that the hospital has a goal of being the safest hospital in the Netherlands and plans to do so by "practicing what you preach" and learning as much as possible from others, in the health care field and beyond.

So it was appropriate that the chair of the symposium committee, Marck Haerkens (CEO of Wings of Care), and his colleagues decided to bring in the lessons of quality and safety from other fields. They see parallels with airline safety, and so we heard from Pieter van Vollenhoven Chair of the national Safety Board; Jos Nijhuis, CEO of Amsterdam's Schiphol Airport, and Tames Oud, head of training for Transavia Airlines.

Tames suggested that, while aviation and medicine are two different worlds, there some striking similarities, such as highly motivated professionals and critical processes. In both worlds safety and quality depend on effective cooperation between different disciplines. Like Captain Sullenberger back in the US, Tames asserted that the medical community could benefit from Crew Resource Management (CRM). Its objective is to reduce incidents (and worse) due to lack of situational awareness and team cooperation. He noted that CRM training makes people aware of the relevance of the human factor in team performance, and aids in creating a blame-free environment for people to work in.

In addition, Scott Higginbotham, mission manager at NASA's Kennedy Space Center, presented on "Safety and Mission Assurance." (He is seen here on the right with Willy Spaan, the hospital's CEO.) Scott's primary responsibility is to lead the multi-disciplinary team of engineers and technicians that assemble and test the experiments and satellites that fly aboard the Space Shuttle and the International Space Station. A summary: Manned spaceflight is an incredibly complex and inherently risky human endeavor. As the result of the lessons learned through years of triumph and tragedy, NASA has embraced a comprehensive and integrated approach to the challenge of ensuring safety and mission success. His presentation provided an overview of some of the techniques employed in this effort.

Regular readers of this blog will know my topic: I presented the experience of my former hospital with regard to its goal to eliminate preventable harm for its patients. I explored the hospital’s success in improving quality and safety for patients, endorsing public transparency of clinical outcomes, and engaging in process improvement driven by front-line staff.

As I have noted before, there are often misconceptions as people talk about “transparency” in the health care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency’s major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Many thanks to the symposium's major organizers, Marian de Bont and Dr. Kees Smulders, secretary and manager, respectively, of Jeroen Bosch's quality section (seen here) for their invitation and for planning a day of interesting and insightful talks.

In the post above, I include recent activities of Dr. Smulders and his staff with regard to new approaches to transparency in their hospital.

Transparency is not about competition

Cheryl Clark at HealthLeaders Media has an excellent story about how making hospital clinical outcome data public affects providers. It speaks positively about the efforts of my former hospital in this regard and quotes the hospital's chief quality officer:

"But transparent reporting's strongest impact has been internal. There's the overall message that we're confident enough in our performance to share information publicly, and the accountability that it signals. It's generated a series of conversations about what we want to make sure we're doing well at, that we're tracking it."

This point echoes a theme I stated back in 2008, based in great measure on something I learned from Jim Conway, which he picked up from the work of Peter Senge in The Fifth Discipline:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

I do have to correct some misstatements in the article, though.  It suggested that our early forays into transparency of clinical outcomes began in 2003, and that the impetus was the following:

Commercial reputation seemed to suggest BIDMC's competitors were better hospitals, "but when we looked at the data, it didn't look that way to us; it looked like we were the same or better. So we felt there was nothing to lose by creating a more level playing field, by making the data available."

Not at all the case.  First of all, the year was 2006, and not 2003, when I began posting real-time central line infection rates on this blog, followed by other metrics, based on great work by our clinical leaders.  And this had nothing to do with competition.  I wrote these pieces because I was really proud of our progress on these clinical issues.  Also, consistent with the points made above, our Chief of Medicine, VP for Healthcare Quality, and I felt that transparency would lead our staff to hold themselves accountable to a higher standard of care.  Our staff had few or no objections, as they felt comfortable that the data were accurate and were not being used to blame anyone for lapses in performance.  The mantra became, "Let's be hard on the problem and soft on the people."

Our Board of Directors, again with advice from Jim Conway but also from Lee Carter, then chair of the board of Cincinnati Children's Hospital, and MIT's Steven Spear, soon got on board and made a huge commitment to the elimination of preventable harm and to the publication of quarterly figures summarizing harm on the corporate website.

That's how it happened.  It required no governmental mandate, just a commitment from the administrative and clinical leadership, supported by the governing body of the hospital.

The experts agree on transparency

It can feel lonely out here when you are beating the drum for transparency as a necessary supportive adjunct to process improvement. So it is really nice when some of the world's experts on the topic are singing the same tune.

I just saw this article, entitled "Truth Telling: Can Your Hospital Handle It?" by Bill Santamour at H&HN Daily today. I promise that I read it after writing yesterday's post. Excerpts:

Former U.S. Treasury Secretary Paul O'Neill . . . said hospitals ought to post rates of nosocomial infections, patient falls, medication errors and employee injuries on the Internet for all to see, and he thinks they ought to do it every day. "Let's bring some energy to this," he said.

Gary S. Kaplan, M.D., CEO of Virginia Mason Medical Center in Seattle, agrees that transparency is key. Improving safety "is really about change management, making our organizations better. How can we do this unless we have an environment of transparency?"

[The government] information reported needs to be a lot more up to date, said Carolyn Clancy, director of the Agency for Healthcare Research and Quality. "We're not so good at timely transparency," she said. "We must get to a place where we get data in something like real time."

My quotes from yesterday:

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

[T]ransparency of data alone is not sufficient. What makes it powerful in establishing creative tension in an organization are: The currency of the data; the fact that the metrics being made transparent have been chosen by those involved in the process improvement efforts; and the fact that the transparent outcomes are supported by a structure of ongoing process improvement.

Parkland Memorial: Will transparency finally rule?

I recently reported about the reluctance of the board at Dallas' Parkland Memorial Hospital to make public the consultant's report prepared by order of CMS to review quality and safety issues in the hospital.  Well, it has not been released, but the Dallas Morning News secured a copy and has reported about it.  Here are excerpts:

Among the findings: Patient rooms were found to contain overflowing trash bins, excrement and blood. Hundreds of medications were improperly administered to patients. Dozens of beds remained empty despite crushes of patients seeking emergency care. Senior leaders kept critical information from the hospital’s board of managers. One patient died, apparently after receiving a drug without doctors’ orders

A new problem area highlighted in the report: the main operating room, which supposed to be among the most sterile environments in a hospital.  Monitors found a dirty, potentially unsterile environment that could sicken patients, cluttered by equipment and in need of repair. Staffers told the monitors that they didn’t know the standards or regulations for cleanliness.

The person newly in charge said what you might expect in the face of this kind of report:

Dr. Thomas Royer, Parkland’s interim chief executive officer, declined to discuss the report Tuesday, but released a statement. “We have instituted leadership changes, formulated new policies and procedures and have begun the reorganization of key departments,” the statement said. “We have made it clear to everyone that unless and until we can honestly say that safety and accountability are at the center of everything that we do, our work will not be done.”

And from CMS, we hear:

“This is a chilling account that demonstrates starkly the work ahead,” said David Wright, deputy regional manager for the U.S. Centers for Medicare & Medicaid Services. “For Parkland to be a safe hospital, fundamental and sustainable change is needed. There is a lot of bad information here, but it serves a purpose. We now have a comprehensive idea of problems.”

I would say that the only way structural improvement will happen is if the hospital opens itself up and adopts a policy of transparency of key clinical measures going forward.  Why?  Imagine that you are on the staff.  You have now been buffeted by incredible levels of adverse publicity and you have been working in an environment that apparently did not sufficiently value quality and safety improvement.  To hold your head high for the future, you will want to prove to yourself, your colleagues, and the community that things have changed and that results have been achieved.  Unless the numbers are made public, and in real time, people's loss of trust and faith in the hospital cannot recover.

Imagine you are in a senior administrative or clinical position. Besides the point raised above with regard to rebuilding trust among the staff and community, you need a powerful motivational tool to ensure continuous process improvement.  Transparency is such a tool.  As recognized by MIT's Peter Senge, adoption of audacious goals and transparency with regard to the current state establishes a creative tension in an organization, leading people to apply energy and commitment towards meeting those goals.  As I have said:

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

I'd love to see someone in Dallas buy into this concept.

No retreat by the Boards

About a year ago, the Boards of BIDMC and BID~Needham met in an educational and planning retreat to decide on their priorities for both hospitals, one a large academic medical center, the other a small community hospital. The result was a four-year commitment to eliminate preventable harm and to dramatically improve patient satisfaction in the two hospitals.

Today, the governing bodies again met to reaffirm these goals, to learn more about how to achieve them, and to plan their agendas for the coming year. They were assisted by some special guests.

First was Steven Spear, Senior Fellow at both the Institute for Healthcare Improvement and the MIT Engineering Systems Division. I have written before about some of Steven's ideas and research. Here, too, he discussed the manner in which the best complex organizations deal with the problem of how to obtain process improvement. He noted that the first step in improving a complex system is being transparent about what is going wrong because "we need to know it's a problem we need to solve." As opposed to a transactional mindset, in which the emphasis is on making decisions because you assume you know enough to make the right choice, he emphasized the value of a discovery mindset. Under this approach, you have to have humility that an educated guess is not likely to be right, but that it provides an opportunity for learning. You also need to be sufficiently optimistic that you will achieve improvement over time, aided by iterative discovery. In short, the key is "humble optimism."

Spear emphasized that one of the jobs of a governing board of a hospital committed to transparency is to stand by the medical and clinical leadership and staff during the inevitable periods in which there will be adverse publicity resulting from this openness. "Watch their back," he advised.

The next session consisted of a panel comprising doctors and nurses from the two hospitals, focusing on their perspective on the progress towards quality and safety improvement and receiving their advice for activities by the Boards that could support these objectives. They were unanimous in their support for the importance of transparency as a key part of process improvement.

Following break-out sessions in which the Boards and their respective committees planned their agendas for the coming six months, they heard from Lee Carter, former Chair of the Board of Cincinnati Children's Hospital, a national leader in hospital quality and safety. He mentioned the key elements of board involvement in the quality agenda:

-- Pay attention and understand what people on the front line are doing so that they know they are appreciated. Improving quality is very difficult and takes extra work. "You need to let them know that you appreciate them."
-- Encourage transparency. "It is powerful and absolutely necessary. Until you identify what you need to improve you never will improve."
-- Establish and maintain a culture of trust, because without it, you cannot obtain transparency.
-- Measure progress, rigorously and accurately. Quoting IHI's Jim Conway, Lee noted, "Some is not a number; soon is not a time." Quantifiable objectives, with specific deadlines, are key, as is measuring progress towards both the objectives and the timeliness of achieving them.

He left the board members with the following lessons from Cincinnati: (1) We are never as good at something as we think we are; (2) it is very hard work to make transformational, as opposed to incremental, change; (3) we always have slower progress than we think we will, and the board needs to understand that and be supportive; (4) it takes persistence, and the role of the board is to support the attempt and be cheerleaders for the transformation. Confirming Spear, he stated that the board needs to let the clinical and administrative leadership know that "I've got your back" during periods of public scrutiny and the adverse publicity that often accompanies transparency. Finally, says Lee, (5), "After all this, it works" and will save lives and will result in better patient care overall.

About 80 lay leaders left the 12-hour session with a renewed sense of purpose and commitment, enthusiastic in their attempt to improve care not only at their hospitals, but also cognizant that they are partners in a national movement to do the same.

Transparency is not marketing

When is transparency not transparency? Answer: When it is marketing.

A recent ad campaign by a well known hospital system suggests that you are better off going to one of its hospitals if you have a stroke because they have a speedy rate of administration of an anti-clotting agent. It is true that rapid administration of this drug is very important.

But the data offered by this hospital system are old, based on the period 2006-2008. According to the Boston Globe, "State officials said that when data for 2009 and 2010 are released next year, they expect the gap between hospitals will have narrowed because of improved care."

Look, no one will argue that you don't get excellent care at this hospital system. Quite the contrary. But to suggest that you will get better care, based on old data, just isn't right. It might even raise unnecessary concern among patients or their families. Imagine, for example, that a loved one is having a stroke and you ask the ambulance to go to a hospital that is farther away because you think that the patient will get faster treatment. The extra time spent in the ambulance might add danger itself.

Also, selective use of clinical outcomes for marketing purposes is a slippery slope. Let's review the issue, for example, of "door-to-balloon" time. The Joint Commission has set a standard for opening blocked arteries with catheterization (percutaneous coronary intervention) within 90 minutes of presentation at an emergency room in a hospital. The hope is to achieve this goal at least 90% of the time.

But one member of this same hospital system only accomplished this standard about 60% of the time for part of 2009. I don't recall a marketing campaign back then that referred to this result.

You cannot be selective about transparency. You have to post the good and the bad. See the VA story below. If you use it for marketing purposes when the numbers are good, you rightfully open yourself up to attack for selective use of statistics.

Let's just accept that transparency is about holding ourselves accountable to a high standard of care and learning from one another, rather than attempting to use it as a marketing tool.

Comparability doesn't matter

I was talking about public reporting the other day with an MD colleague.  He pointed out that hospitals often have different definitions for a variety of measures, like ventilator associated pneumonia (VAP).  Therefore, he pointed out, public reporting of such measures can be problematic.  I said, "No, it's not a problem."

Why not?

Let's look at what we are trying to accomplish.  Simply put, we want the hospitals, doctors, and nurses to engage in systemic process improvement in their institutions.  What are the elements of doing that?  Brent James lays them out quite clearly, based on the concept of shared baselines:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

That is the essence.  Now where does public reporting come in?  The impetus for transparency of clinical outcomes can be found in the writings of MIT's Peter Senge.  In The Fifth Discipline, he discusses creative tension.

[T]he gap between vision and current reality is . . . a source of energy. If there was no gap, there would be no need for any action to move toward the vision. Indeed, the gap is the source of creative energy. We call this gap creative tension.

Imagine a rubber band, stretched between your vision and current reality. When stretched, the rubber band creates tension, representing the tension between vision and current reality. What does tension seek? Resolution or release. There are only two possible ways for the tension to resolve itself: pull reality towards the vision or pull the vision towards reality. Which occurs will depend on whether we hold steady to the vision.

So the deal is this.  You establish an audacious goal for your organization, one that truly stretches everyone.  You publish that target for the world to see, and you also regularly publish your progress towards that target.  The gap between the current state and the future state helps to drive your organization towards the target.

As I have mentioned: 

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

There is nothing in this construct that requires one hospital to use the same metrics as another.  Indeed, I would suggest that having an external authority (e.g., a regulatory agency) establish a common metric will often undermine, rather than support, process improvement.  Why?  Because the internal constituencies who must buy off on the need for process improvement will question the applicability and accuracy of that metric.  Resentment will arise, and progress will slow down.

I can feel people getting antsy now.  "We need comparability in public reporting so consumers will know how to choose among hospitals."  Nonsense.  There is virtually no evidence that the public uses clinical information from websites to make choices as to where they get treatment.  Jeez, when Bill Clinton needed heart surgery in New York, where mortality rates of the hospitals are publicly available, he went to one that had among the highest figures.  (OTOH, maybe Hillary sent him there . . . but that's another story!)

I have addressed this point before, also.

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Seriously, are you really likely to decide on where to get ICU care based on the rate of VAP?  Even for elective surgery, you are most likely to go to the hospital or specialist recommended by your primary care doctor.  If you have cancer, you don't choose hospitals based on infection rates.  You do your research and make your choice based on many other factors (e.g., empathy of doctors, availability of clinical trials.)

I want to be clear that there is value in having a government requirement for transparency, but -- in most cases -- I would leave it up to the individual hospitals to use the definition of each metric that most suits them.  If we tell them what metric to use, we have taken away the self-accountability that we want.  Require them to post their goal and their progress.  Let them add editorial comments about why they chose the metric they did.  What we want to see is that they improve and that they maintain and sustain their improvement. Comparability with other hospitals simply does not matter.

A turning point for Partners Healthcare?

As we look back at the history of Partners Healthcare System (PHS) in Massachusetts, it is useful to consider what it is and what it might have been.  What it is is an extraordinary collection of extremely dedicated and talented people--clinicians, researchers, and teachers--who do their best to serve humanity.  What it is also is an incredibly successful business enterprise, carrying out a series of strategic plans that have led to market dominance in Eastern Massachusetts.  What it is not is a leader in quality, safety, process improvement, and transparency.  As I noted in March 2009:

The Partners hospitals are full of well intentioned, dedicated people. But there has not been a corporate public commitment to reduction of harm and to transparency of clinical outcomes that could help build broad public confidence in the quality and safety of patient care -- and with this a confidence that we are also attempting to control costs. . . . The Partners system should be a world leader in the science of health care delivery, along with the fields in which it already holds prominence.

I'm not the only person to notice this.  As I have traveled throughout the country, I often find people curious as to how a health care system that has comprised people like David Bates, Atul Gawande, and Tejal Gandhi has failed to adopt the principles espoused by, and to utilize the guidance of, these world-class experts.

I believe--although there is no way to prove it--that if founder Richard Nesson had lived longer and had thereby been able to exercise a lasting influence on the heart and soul of PHS, that this would have occurred. As noted in this obituary, Nesson had a deep connection to community service and to people's well-being, as well as a thoughtful sense of business matters. In the absence of his social conscience, the leadership of PHS has focused on influencing the body politic and building its business presence more than on the leadership role it might have taken in quality, safety, process improvement, and transparency.

But a recent announcement has given me hope.  Gregg Meyer, MD, is joining the system as Chief Clinical Officer in January.  Most recently, Gregg has served as Chief Clinical Officer and Executive Vice-President for Population Health at Dartmouth-Hitchcock and as the Senior Associate Dean for Clinical Affairs and Paul B. Batalden Professor and Chair at the Geisel School of Medicine. While he was formerly at PHS, it was in a more limited role at MGH. Now, he is moving up to a system-wide position.

This has the potential to be the most significant single appointment at PHS in many years.  Gregg has substantial expertise in the matters I have discussed, but he also has an insider's view of how to achieve change and deal with the many political jurisdictions within this spreading healthcare system. I believe that he is not the kind of person to take on the assigned task without having received assurances from the top leadership that they will support his efforts--and without a personal belief that he can succeed in helping to transform this system.

But it is late in the game, if the goal is to offer PHS to the world as a leader in quality, safety, process improvement, and transparency.  Other systems--including but not limited to Ascension, ThedaCare, and MedStar--have head starts.  Each of them intends to be "the best at getting better." Importantly, too, each of them approaches the task with modesty, being unafraid to admit where they need to improve and learn from others. PHS has been a bit short on the modesty front over the years. I'm hoping Gregg's arrival not only is a sign of corporate commitment to a quality and safety agenda, but is also a sign that the arrogance characterizing this system is on the wane.

Seeing clearly at MedStar

I was pleased to be invited to the quarterly Quality and Safety/Risk Management Retreat at MedStar, a hospital system that has adopted audacious goals for improvement in these arenas.   My topic was on the power of transparency in helping to bring about the kind of organizational change needed to deliver consistently high quality care to patients.  I found an attentive and engaged audience of people from all of the MedStar hospitals, hosted by David Mayer.  David (below, left) was brought into the system in the last year to lead its quality and saftey transformation.

My theme, as regular readers of this blog will expect, is that transparency's major value is in providing creative tension within hospitals so that they hold themselves accountable to the standard of care in which they believe.  This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

For me, a measure of how well a hospital system is doing is the degree of modesty displayed by the leaders and staff when you ask, "How are you doing?"  Here, David asked the question of the attendees:  "On a scale of 1-10 (10 being the most transparent), how transparent is MedSatr compared to other hospitals and health systems?"  Also, "Provide one example of how MedStar can become more transparent with its patients and with its associates."  The discussion groups met for a while and returned with the following verdict:

I actually think the participants were a bit hard on themselves.  I think their assumption about the level of transparency at other hospitals was too high.  From my view, MedStar is already above average.  Of course, as I noted today, there is no virtue in benchmarking yourself to a substandard norm!  MedStar has a ways to go on the transparency front, but it is off to a good start.

I left with a terrific impression of the energy and good intentions of those in the room.  The level of participation and engagement was exemplary.  This is a system worth watching over the coming months and years!

Transparency? Not here, please.

Our friends at The Health Care Blog have posted a letter from the founder of C-SPAN to Speaker Pelosi asking for televised proceedings of the health care bill conference committee. This has generated lots of comments.

I think this is a bad idea. Maybe this will surprise those of you who know me for pushing transparency. But the world of negotiation requires some privacy.

The C-SPAN fellow confuses transparency of result with transparency of process. Sometimes, the process needs to be held in confidence to build the kind of trust you need to reach an agreement.

Negotiations like this need to be held in private for effective compromises to be reached. For example, part of a negotiation is for each party to discuss how they are going to help the other party persuade his/her colleagues to go along with the negotiated agreement. You can't really talk about such things in public.

If this set of meetings is broadcast, the real negotiations will take place in a quiet room somewhere else on Capitol Hill.

Seeing things clearly in the Netherlands

In the post below, I summarize a conference held today at Jeroen Bosch Hospital in 's-Hertogenbosch (den Bosch), in the Netherlands, entitled "Quality and Transparency in Care and Training." In addition to the conference, today was a significant day in that a new website was launched by the hospital to present quality and safety data to the public and to the hospital's staff.

As explained by Dr. Marjo Jager, patient quality specialist, Jeroen Bosch has a strong commitment to transparency as a key element of process improvement in the hospital. The leadership of the hospital views transparency as the most powerful way to reduce preventable injuries, but also as essential to successful and ethical responses to patients and to safeguard employees.

Marjo noted that preconditions for successful implementation of transparency are a culture of learning rather than blaming and judging; ownership by those who deliver care; significant participation by physicians in designing new care regimes and setting an example; and strong support from the board.

Above you see an action shot of the moment of truth, as staffers Miriam Casarotto and Bart Deijkers prepare to push the "activate" button on the new website.

Beyond the website, the hospital is also posting clinical data on patient care floors for all to see. They are experimenting with locations and topics, and this is all bound to change with experience, but the commitment to openness is evident, even when the numbers indicate a need for improvement.

Here, for example, is the current scoresheet with regard to pain management on one of the floors. The hospital clearly indicates a result less favorable than they would like, accompanied visually with a cartoon face that is not smiling.


In contrast, note this one with regard to avoiding decubitis ulcers (bedsores), which indicates performance at the hoped-for standard of care.

Congratulations to the administrative and clinical leadership of the hospital, and for the support provided by its board, for these significant steps in improving the quality and safety of patient care.