Friday, August 10, 2007

Our Joint Commission Report

A I mentioned a couple of weeks ago, BIDMC had an unannounced visit from the Joint Commission. At the time, I promised you that I would publish the results of that review. Following is the email I sent to our staff today. Here again is the link to the full report.

As many of you know, we recently had a visit from the Joint Commission, the organization that accredits all of the hospitals in America. The surveyors from the Joint Commission spent several days here in intense review of our physical facilities, our information systems, and -- most importantly -- our actual delivery of care to patients. As is the current practice, this was an unannounced visit, with the surveyors showing up on a Monday morning with just a few hours notice. The people who came were excellent, thoughtful, and comprehensive. As I will discuss below, they found some things that needed improvement, but they also had many compliments for the hospital in general and for many, many of you in particular. They were struck by how many of you came up to them to explain what you were doing and to demonstrate our clinical approaches and advances.

I want you to have the advantage of their work product, so I have posted it on our website. Please read it. Here's the link: As far as I know, this is the first time that a hospital has made its Joint Commission report available to the entire staff and to the world at large. Doing so is consistent with our approach to quality and safety matters here at BIDMC. We believe that sunshine is the best disinfectant!

To summarize, there were three types of areas in which the surveyors asked us to make improvements: clinical process, infrastructure, and administrative. In all, they found eight areas for required improvements. I am not going to go through all of those here, since you can read them yourselves, but let me hit a few highlights as I see them.

First is medication reconciliation. We have the most advanced clinical support systems to help providers ensure that they know the full range of medications being taken by a patient. Our electronic medication reconciliation system enables any clinician, at every encounter, to review all the medications a patient is taking, then verify they are correct or modify them to indicate that the patient is not taking them. Additionally, we can record medications provided at an outside institution, document over the counter medications purchased at a drug store and even record medications with uncertain dosages that a patient reports receiving from other providers. All of this information is used to perform safety checks such as drug/drug, drug/allergy and drug/food interactions.

(By the way, in September we go live with a cutting edge medication history system that will display dispensed drug history from every pharmacy and insurance company in New England. This system, part of MA-Share e-Prescribing gateway, will check drug/drug and drug/allergy interactions among every medication a patient has ever received from any clinician in our region, including medications prescribed by Partners Healthcare, Lahey, Caritas, and private practices.)

But a system like this is only as good as it is being used. The Joint Commission surveyors found that there was uneven use of this powerful system by our doctors and suggested that we enforce it hospital-wide. We agree totally. While many doctors use the system daily, others have avoided it. This is probably understandable, in that some doctors like to be "early adopters' and others are a bit slower to utilize new technology. Over the coming weeks and months, we will make use of the system mandatory.

A second area is the history and physical exams that are performed on patients before surgery. Here, we had a certain system in place, but we learned during the survey that our approach was not quite in compliance with the current Joint Commission standard. Once the surveyors pointed this out, we immediately corrected it, and we believe we are now in conformance with the current standard.

A third area was the security of medications in our code carts, both on the floors and in the supply assembly areas. Certain medications need to be protected so they are not available and stolen or misused. We are fixing this.

On the infrastructure front, the surveyors found a variety of items. For example, some gas canisters were not properly secured. This is a true public safety hazard. If an unsecured gas canister falls and the regulator breaks off, the heavy tube can be an uncontrolled projectile. Another example is that several of our fire doors had gaps of greater than 1/8 inch between the door and the door frame. Again, a public safety hazard that we will fix.

The next step in this process is that we have 45 days to submit plans for required areas of improvement to the Joint Commission. We are also permitted to appeal the surveyors' report if we think that they were in error on one point or another. That sometimes happens because, notwithstanding good intentions, the surveyors cannot necessarily get a full picture of all items during a one-week visit. We are likely to appeal one or more of the areas that were found to require improvement. This does not mean we would avoid actually making improvements in those areas -- it would only mean that they would not be a formal requirement for our re-accreditation.

The upshot is this. We did very, very well. On average, the Joint Commission finds 10 or more requirements for improvement in their hospital surveys. We had eight. Our re-accreditation is secure. The areas in which they found us wanting were legitimate and proper, and it is our job to fix them. The good news is that we were not surprised. Most of the areas they pointed out were on our agenda to fix over the coming months as part of our continuous improvement efforts.

I have often said that, if the Joint Commission did not exist, we would want to invent it. An objective outside review of this sort is extremely helpful to a hospital as it strives to provide better and better care to the public. I want to thank the hundreds of you who interacted with the surveyors in such an open and positive way during their visit, and to the thousands of you who were ready to do so.


Paul F. Levy
President and CEO


Anonymous said...

Paul, congrats to you and all of BIDMC for this excellent outcome from your survey. Congrats also you to, the trustees, executive leadership, and staff for the courage you are showing in releasing your report so publically and immediately in the name of your service to patients and their families.

The fact that you have defects is not unique... every large complex organization has defects. What is unique is how tranparent you are, how you celebrate and respond to learning and improvement, and how committed you all are to address the cited defects asap.

It is a wonderful test of change that you are conducting and we all look forward to the learning arising from it. I suspect at BIDMC what has already quickly arisen and been learned is PRIDE.

Thanks, Jim Conway, SVP IHI

Anonymous said...

Kudos also. I sent it to some former colleagues who are having trouble with their medication reconciliation process. JCAHO has probably proven its worth this time just in mandating universal use of the system in your place.

I have heard JC's new system of reviewing current charts and following actual care is much tougher than the previous predominantly document- and interview-related inspections. Was that your experience?

Anonymous said...

It is absolutely more rigorous -- and appropriately so.

Toni Brayer, MD said...

Congratulations on your survey and special thanks for sharing your results in such a positive manner. Med reconciliation is a challenge for everyone and we are just starting to develop processes that work throughout the hospital. Good work!

Anonymous said...

Kudos to you for posting the JCAHO review. As a preliminary medicine intern, I've commented before on your blog (and today am going to take up your challenge to not be anonymous).

We at BIDMC could push ourselves even more by providing easily accessible, transparent ways for patients and their loved ones to submit suggestions and criticisms about their experience with our hospital. During my few months here, I've noticed how difficult it is to actually locate any suggestion boxes, or to determine which office is responsible for acting on patient concerns. To help facilitate feedback, I've actually taken it upon myself to email you through your blog, about a patient's less-than-positive experience with BIDMC phone operators.

The "Patient Relations Office" link on the "Contact BIDMC" page is a good start, but it's unwieldy as it requires a mail client like Outlook to be installed. Why not a more obvious one-click link, shaped like a suggestion box, right on the main homepage, instead of buried inside... one that is simply a form people can complete online, without any extra steps--like the "Refer a Friend" functionality we have?

Many of our patients are either older, possibly not technologically inclined, and frankly don't have access to computers while they are inpatients. Installing obvious suggestion boxes with plentiful comment forms at each floor's front desk, and providing forms in patient rooms, would elicit greater, more real-time feedback. And to ensure that we are really responding to patient feedback, why not post the good and the bad on our floor posterboards? I realize nurse managers are busy, but going through the suggestion box to assess our patients' satisfaction helps us meet our patients' needs. Higher patient satisfaction = more referrals = better business for BIDMC.

Heck, I feel so strongly about this that I'd even volunteer to help out with improving feedback mechanisms, even during my hectic life as an intern.

Tom Quinn said...

Congratulations to all at BIDMC on your successul survey. My hospital is due its unannounced survey at any time. Your candor is a model and an encouragement to all of us.

Mark Graban said...

First off, I do admire you for publishing that document for the world. Sunshine is the best disinfectant.

I have to ask though, and this coming from someone relatively new to healthcare from the manufacturing industry. How can management let obviously unsafe conditions, like unsecured gas containers, go unchecked? Why does this require an outside inspection to uncover?

Why not be more proactive in your improvement efforts? How do you plan on holding managers accountable to make sure safety problems like that are audited on a continuous basis so they are never again found by outside inspectors?

Anonymous said...

I think it would be an unusual manufacturing plant, covering about 3 million square feet with about 10,000 workers, to not have any safety violations or other problems. That being said, we do audits and surveys ourselves, and we do hold managers accountable. We are always looking for better ways to do that, and we are borrowing techniques from other industries.

Not offered as an excuse, but just part of the explanation: Please remember that this is not a manufacturing process, with constant production of a constrained set of identical products. Remember, too, that a key component of our workforce (i.e, the doctors) are not employees and are therefore not subject to the kind of direction and supervision of employed staff.

But, to your point, from what I have seen of health care, it is a cottage idustry thus far with regard to the kinds of issues you raise. I am more familiar with other industries, in which the expectations are different and the understanding of systemic quality improvement is much more advanced.

Anonymous said...

To Tom and Toni and Jim,

Many thanks.

To Victoria,

There is an email in your inbox giving you the contact to join in and help! Thanks for writing.

Mark Graban said...

Paul, I'm glad to hear there *is* an audit system in place, with accountability. And you're right, nobody is ever perfect (even a Toyota facility).

It's good that your hospital is learning from other industries, but please don't diminish the challenges of manufacturing. It's a rare factory that just cranks out the same products over and over.

I do understand the point that physicians as independent contractors is a unique challenge.

But, your other comment comes across as somewhat demeaning to the simple manufacturing business. It certainly doesn't seem like a valid explanation that "we have complex processes." Would Intel use that as an excuse, considering they have probably the most complex and high-tech manufacturing processes in the world?

Anonymous said...

I'm seeing this a couple of days late, but since nobody else has mentioned this perspective, I will.

Having been admitted to BIDMC as a patient 7 times this year, I quickly recognized some of the programs you mentioned. And being a process nut myself, it's fun to recognize those initiatives playing out in the real world (MY real world).

The most obvious is what I now recognize as the medication reconciliation system, as workers studiously reviewed all my meds at each admission. (Good thing, too, because usually some med had been discontinued since last visit. I was sometimes being admitted for truly risky treatments, so I'm truly grateful for the effectiveness of the extra caution.)

Separately, from earlier posts I was aware of BIDMC's initiative to reduce central line infections. Having had central lines inserted during 4 of my admissions, I'm especially grateful for that initiative!

Applause applause for every health care provider who vigorously pursues improvement, and triple-applause to those who practice "sunshine is the best disinfectant." Hoorah, hoorah.

Anonymous said...


The difference is between producing say, 12 or even 20 identical products, really well over and over -- and producing highly personalized and individualized medical services 600,000 times one at a time. (A male patient with liver cancer who is 80 years old, with dementia, speaking Portuguese is a very different case from a female 30-year old, mentally healthy, English-speaking person -- not only biologically and medically different, but different in terms of what is required for patient and family communications. Just imagine the permutations of what we see here!)

I don't mean it to sound at all demeaning to any manufacturer, but this is solving a quality control problem of a different order of magnitude.

Mark Graban said...

We're going to have to agree to disagree maybe. I don't mean to hijack your discussion, but it's a rare factory that's as simple as "12 or 20 identical products."

I'm not discounting the complexity of hospitals, but you were right the first time that the complexity is not an excuse for quality problems.

Mark Graban said...

Another thought -- just because you have 600,000 unique patients, that doesn't mean you have 600,000 completely unique patient pathways through your hospital. That overstates the complexity of the hospital.

Anonymous said...

Mark, I'm glad you are bringing this up and you are right, to some extent, as seen below:

There is some ability to standardize things, but the key difference is that the delivery of care at its heart is a series of one-to-one interactions between a nurse, doctor, or other provider and a patient and the patient's family. So, sure, to use the example to which I link above, there is only one "Whipple" procedure is a way, but each patient gets a different one, and the surgeon is making real-time decisions throughout the process based on that person's biology, the state of the disease, emotional status, and such. So the clinical pathway provides helpful guidance, but a lot is left to judgment in the moment.

I've been involved in tons of other fields before this and have never seen this level of complexity. Sure, an auto manufacturing plant produces customized models of each car, but the item on which the workers are working is an inanimate piece of metal and plastic, not a human being.

Anonymous said...

I am interested in the discussion between Mark and Paul regarding standardization of processes in health care. I was about to jump in and say that some hospitals and hospital segments (such as laboratories) have been starting to use such techniques as Six Sigma and Lean to attempt to standardize processes - then I discovered that Mark is a Lean consultant! I see wherefrom comes your viewpoint!

As someone who has been involved in trying to standardize process in a clinical laboratory and its interfaces with nursing, I would say absolutely yes, there is interest in standardizing process in hospitals. Every operating room every day in the same hospital, for instance, should use the exact same procedure to order blood from the blood bank, transport it to the correct room, verify the correct blood type, check the patient's identitiy, and hang the blood. We discovered after a transfusion-related death many years ago that in fact there was no such standardization, at least in cardiac procedures. Patient armbands were being cut off during line insertions, and every OR nurse and anesthesiologist had their own way of identifying the now-unidentified patient under the drapes - including writing the name and medical record number on the leg of their scrubs!!!
Certainly processes like that can and should be rigidly standardized.
Paul is referring to the higher-level intellectual processes that go on in making clinical care decisions for the individual patient.

So I think you are both right. It is no longer acceptable for health care continuing to use the same tired "we're too complicated for standardization" excuse, but on the other hand you can't just shove hospital processes straight into a pre-fab process efficiency model, either.

Anonymous said...

Aha! You see, Mark and I were vigorously agreeing after all!

Mark Graban said...

Lest I be accused of protesting too much, yes, I am a Lean consultant. I'm not hiding that. I'm a Lean consultant not because of a cynical attempt to jump on a bandwagon, but because I've personally worked with and seen the methodology work wonders my whole career. And I'm passionate about bringing that sort of improvement to healthcare. I'm not just trying to dump on the industry, I really am trying to help, each and every day.

The process is about collaborating with hospitals to figure out how to apply Lean concepts to solve their problems. It certainly isn't about "forcing" anyone into a "pre-fab" process efficiency model. It's "pre-fab" in the sense that it's proven to work in any industry. What's wrong with that?

Now, bad consultants will take isolated Lean tools and force fit them where they don't belong. That should be avoided like the plague, I would agree.

So we're all agreeing and disagreeing. What fun. Maybe we need a separate thread to discuss the ins and outs of Lean, I really do apologize for hijacking this one.

One final thought on Standardization --- this isn't about "mindless conformity" (as Bill Marriott brilliant states). The Toyota/Lean model is about engaging employees to define their own standards (rather than being dictated to by managers or consultants). It's also not a permanently fixed standard, it's meant to be improved upon, by those same workers and teams.

The higher level intellectual process that Paul is talking about -- yes, that would be much harder to standardize and this isn't about turning doctors or nurses into robots.

Standardize what you can and standardize the things that matter -- the things that improve quality, safety, and cost, so we have a good environment for our medical geniuses to work in.

Anonymous said...


I entirely agree with you about standardizing what you can. I wasn't meaning to "out" you about being a Lean consultant; just that it informs your viewpoint.

I especially agree with you about the employees defining their own standards (or at least defining how they will meet those standards.)
In the example I gave, that's actually the only thing that worked. We first tried to solve it with the top-down method, with the OR Administrative Director trying to enforce a solution that she and the nursing VP came up with. There were a million (valid) objections. Then I went to Anesthesiology, but as Paul points out, they are not employees, each one felt that they had the process "covered" adequately, and were not interested in a standard process. Finally, I went through the OR nursing education coordinator. Turned out the nurses themselves had been worried sick about the lack of standardization. Given some background education by me and some brainstorming, they came up with a solution, sold it to Anesthesia, wrote it into their manual and were off and running! Several came to me later and said they were very relieved to have gone through the process.

I see Lean as helping to provide a structure for all that. It just has to be applied flexibly.

Mark Graban said...

That's a great story, anon! Glad to hear it. Whatever methodology we use, lean or otherwise, what matters is improving the process, for the sake of the patients and the employees!

I didn't feel "outed" (since I don't hide that in my linked bio... I still probably should have stated it in the post to get my bias out in the open).

Anonymous said...

The truly scary part of that story is that only the rank and file OR nurses and the blood bank (of which I was Medical Director) recognized the situation as a problem. The administration and anesthesiologists were only humoring me because we were under pressure due to an adverse inspection.
THAT's why, as Paul says, one would want to invent JCAHO if it didn't exist (although this was a state inspection). And why administrators should not only permit, but every day encourage clinical employees to speak up if they perceive a problem.

See, I did manage to relate our discussion back to the JCAHO inspection. (:

Anonymous said...

I just pulled up the JCAHO report on the BIDMC website and it appears that pages 15-19 are missing. The report stops on page 14 of 19. Why is that?