Saturday, February 17, 2007

Who do you think you are, anyway?

For those of you not on the inside of the health care system, here is the scuttlebutt around Boston. Some of my colleagues out there are saying to one another, "Who does he think he is, a non-MD, posting clinical information?" "Why is he so far out front on this issue?" "Doesn't he know that these blog postings are bad for academic medicine?" "This is all being done just to make his competitors look bad."

Here is my view. First, let me address the last point. I plead guilty to being highly competitive, but I took over a hospital that was almost driven out of business, both by bad internal management and by aggressive actions taken by other hospitals in town. I think the people at BIDMC -- and I mean everybody -- doctors, nurses, techs, housekeepers, transporters, and food service workers -- have something important to offer the community. I dearly want our place to thrive so they can deliver on that promise, and I will look for a competitive advantage where I can find it.

John McDonough, on the Health Care for All blog, has suggested that high quality care can be a competitive advantage. Maybe, maybe not. I do know, however, that some other hospitals in town can ride on their reputation, rather than on their comparative performance. I also know that some other hospitals in town are reimbursed by insurers based on market share, rather than on quality of care. If people are given accurate data on quality and safety, and if these perceptions and patterns shift as a result of that transparency, so be it.

But I believe that the more important issue for all of us running hospitals, and especially academic medical centers, is that our standing as institutions in American society is in jeopardy. In many respects, people do not trust that we are there to serve them carefully and efficiently. Some think, too, that we do not have proper respect and concern for our workers. Some also think that we do not have sufficient involvement in the community. Here in Boston, the hospitals are now the largest corporations in the city, in terms of staffing, revenues, physical facilities, purchasing, energy use, and the like. By virtue of that standing, we are now expected to meet a higher public standard than has ever been the case.

I know that the people at BIDMC are trying to meet that higher standard. We may falter, and we will make mistakes (sometimes really bad ones), but we are setting ourselves to carry forth the legacy of our two antecedent institutions, the New England Deaconess Hospital and the Beth Israel Hospital.

The description of the Deaconess -- "where science and kindliness unite in combating disease" -- was also the watchword for Beth Israel. Fortunately, the combined institution that resulted from the merger ten years ago maintains that set of values. BIDMC stands as a place where patients know they will be treated with warmth, friendliness, respect, and dignity. We do our best to treat each person as we would want a member of our own family to be treated. This is not just a saying: It is part of the culture of the place, and we deliver on that promise every day and night in the great majority of cases. We aim to continue to show our patients that level of caring and respect.

But this has to be combined with excellence in the delivery of patient care -- and particularly minimizing the probability of causing harm to patients. Clinical quality emanates from the judgment and experience and skills of world-class doctors working with world-class associates like nurses and technicians. But even that expertise sometimes needs help and new management approaches to overcome systemic problems in the organization. As I have tried to reflect in the postings below, we have aspirations to be as good as we can possibly be in that arena. We believe that public disclosure of our progress is one tool in reaching those aspirations.

I hope you agree that more widespread disclosure by all the Boston hospitals would enhance the performance of us all and would build public confidence in the great academic medical centers in our community. I like to think that we will eventually live up to the expectations set forth so clearly by Patient Dave in his heartrending comment on the posting below:

NOBODY has more right to that information than the patient in need. NOBODY.

This is REALLY personal, believe me. If we can easily get info on the best used cars (hardly a matter of life and death), we certainly ought to have free access to information on who has high and low outcomes and accident rates.

We owe it to ourselves and the community to make sure Dave and all other patients get what they need.


Anonymous said...

Re: "This is all being done just to make his competitors look bad."

I can understand that view, especially as we start to disrupt a culture that says performance and quality stats are none of my business.(!!!)

People aligned with the existing culture might, temporarily, feel uneasy when we start publishing what feels like the intimate details of one's own successes and failures.

But that's exactly the point in Paul's closing remark: "This is an attempt to get past a culture of blame and litigation and persuade people that transparency works." Huzzah.

Re "make his competitors look bad": A danger of blogging is that we can easily get a link to a single article, out of context of the whole blog. Please look at the list of topics in the "Recent Posts" panel on the right:
- We saved one person's life. Can we keep it going?
- Congrats to them, and us!
- New Feature: Personal Story Links
- A Worldwide Hope -- More on Preeclampsia
- Governing Safety and Quality
- Little ideas work, too
- Change must come from within
- Congratulations to our competitors
- Thank you, Allegra Goodman

Doesn't look to me like a slander campaign.

And look at what Paul said about the BIDMC board's scrutiny in his post "Governing Safety and Quality":
First, said our advisers, the board of trustees is seeing [too many metrics that always look good]. ... Instead, focus the board's attention on where you are doing harm to patients, and tell them how you are going to stop injuring and killing people."

Please, people, this approach can work! In the management world in recent decades, initiatives such as Six Sigma have produced enormous quality improvements. It starts with defining quality from the *customer's* perspective, then being open and trusting with each other in the common hunt for continuous improvement.

Should we in health care do any less?

Please keep working toward what's good for patients. From where I sit today, no matter what your intention is, anything that impedes improvement comes dangerously close to violating "First do no harm." And I KNOW that's not anyone's intention. We just need to trust each other and share that goal.

Anonymous said...

Dear Paul,
I have worked tirelessly for the past six years trying to change a culture of secrecy and non patient centered care, following the death of my child. I applaud your courage to stand up for others and believe in yourself. Please continue to be the leader that your staff and patients can be proud of and don't worry about those that have yet to see the light. Thank you!
~a mom

Alexis said...

As someone who doesn't live in Boston, or even on the East Coast, I find your blog invaluable as an example of how to make the health system both more honest and more accessible. I think you've put yourself in a very risky place - your blog, unlike mine, will receive the equivalent of constant peer review, and potentially have a huge impact on your community and career. That takes guts, frankly, and I think it makes your blog a great thing for academic medicine. Too often, our disagreements or opinions remain behind the golden gates of academia (this is true in more fields than medicine), because we sometimes cling to the letters behind our names as if they give us more right to information than everyone else. If it makes your competitors look bad, then they should start blogs. Openness and honesty are qualities to strive for together - if anyone looks bad, it is because they belittle someone for trying to achieve these characteristics, rather than through any action of the "someone" in question.

In the past year, we've seen the larger scientific community opening up through initiatives like Nature's open peer review experiment. The health system needs to move forward in the same manner, rather than hide behind "staff-only" doors. Blogs could be a huge part of this, especially if people in positions of relative power are willing to put themselves in the spotlight in the name of accessibility.

As for "who do you think you are?" Well, I would guess you're someone whose blog people are reading because you have something worth reading - the larger internet community couldn't give a fig about your position or your salary, except in how it impacts your insight. This can only be a good thing for the future of medicine - even if we don't always agree, we at least can argue out in the open rather than in the boardroom.

Anonymous said...


Keep up the good work. Your leadership and belief in transparency will undoubtedly insure continuous improvement at your hospital. Your critics around town are the ones with their heads in the sand. If they keep it up, maybe the public will wonder what they're trying to hide. If they also embrace transparency, wonderful. If they don't, I hope BIDMC is rewarded with more patients.

By the way, anything you and your colleagues can do to bring about the regulatory change needed to allow disclosure of actual insurer reimbursement rates (as opposed to chargemaster rates) would also be helpful.

Anonymous said...

I'm a little surprised at your colleagues' comments/impressions on your posting of factual data that, if used correctly and in the right spirit to improve learning and dialogue across the healthcare system, could be a very powerful change agent. Every other industry does this, and while healthcare is certainly a more complex industry than most, there is not much to be gained from keeping data secret. The notion that only clinicians can interpret trended information, if that is where concern about sharing information comes from, frankly seems a little condescending. I don't understand how you can truly say that you involve patients in their own care without this open discourse.

There's a good reason for sharing this information beyond the competitive advantage implications. If one hospital is doing something right, shouldn't we be sharing that information across hospitals to collaboratively improve patient care? I'm not sure how you do this without data transparency. The stakes of not sharing this information are too high, in that you lose an opportunity for nimble system-wide improvements in the care of human beings.

Further, I'd imagine that your clinicians and other staff take note of your postings in the public realm, and hope that it creates a sense of pride in what they are accomplishing. Perhaps the spotlight also encourages people to do even better - though as you point out, people who are invested in caring for others would strive to do so anyway:)

I do think that it takes a tremendous amount of courage to open yourself up to such public scrutiny, and you set an exemplary standard for open communication. I know of few chief executives who are as reachable and as open to comment and suggestion from within and outside their organizations. Your blog creates a forum for a level of sharing and teaching that is quite extraordinary. Please keep pushing the envelope!

Bwana said...
This comment has been removed by the author.
Bwana said...


Not that you need any more encouragement or even a pat on the back, although you'll take both!

My words of solace and comfort to you are:

Your approach is likely to lead to (i) improvements in the quality of care; or (ii) improvements in the delivery of care; or (iii) improvements in patient experience; or (iv) a heightened awareness of the limitations on institutional and sytemic delivery of health care.

Or, it is possible that none of the above will happen -- of course, item (iv) is a given, I think, and the rest are likely.

The one thing we know is that your approach CANNOT and WILL NOT makes things worse -- except for you, when you are in the company of the flat earth or geocentric ancients.

Keep it up!!


PS - I removed the original comment since I wrote "heliocentric" instead of "geocentric" and I didn't want your readers to ask "Who does he think he is, anyway?"

Unknown said...

I am not at all surprised by the reactions of your colleagues. You are creating a change that may be hard to stomach for numerous reasons.

I love how Dr. Faust said it in her NPR interview this morning.

"Change is often frightening. That doesn't mean we shouldn't do it. It just means that we should recognize that it can be difficult and figure out the ways to make our way through it most successfully."

A female historian Harvard president? Who would have thought? Hospitals posting their patient safety data for public viewing?

Change is frightening, but I'm encouraged that BIDMC and a few other orgs have taken the steps to lead the industry in the right direction. Hope we all follow your footsteps sooner than later.

Anonymous said...

Paul, This is a fantastic service and forum. There's no doubt that good things must come from this.

Jacqui said...

Dear Mr. Levy

I am a Boston University public health graduate who would like to express my admiration of your continuous openness about clinical and public health issues. Whether it be infection rates at BIDMC or otherwise, your transparency is remarkably unique...and so essential to our healthcare system both in Boston and as a whole.

I am taking time off after graduating to narrow down my long-term career goals, and looking at the progress that you have made at BIDMC, as well as your attitude about more global issues related to healthcare and otherwise, has made me increasingly interested in healthcare management.

While my applause may seem a mere golf clap amongst a raucous of cheers, I hope that you can hear me, a mere member of the community, and provide continued remarkable institutional and community service.