Looking for your help

A short introduction is called for here. Over the past two years, I have shared things with readers of this blog that usually are not made public by the CEO of an organization. I have done so because I think the issues facing hospitals are of sufficient societal import -- i.e., beyond the particular interests of our own hospital -- that they warrant public attention and discourse. Further, I believe that academic institutions like ours have a responsibility to provide educational materials to others, and what works better at that than real time case studies of what we are going through?

In so doing, I show us for what we are in real time, warts and all. This makes us vulnerable to nasty anonymous commenters in the blogosphere, as well as to people who think they benefit from embarrassing us and making us uncomfortable. And, even a few of my board members have said, from time time, "Transparency is one thing, but did you have to post that?" The answer is that this is an experiment in real time, but that I believe BIDMC ends up being a stronger, more effective, more efficient, and more humane organization for having done so.

Here comes the next example, an email I sent out over the weekend to our staff, entitled "Looking for your help." It is self-explanatory. As always, I welcome your comments:

Dear BIDMC,

As you can imagine, I've been giving a lot of thought to the events of the last several weeks with regard to the MRSA infections and the lapses found by DPH and CMS in our hospital with regard to infection control. We have already made some changes in response to those findings that should be quite helpful, but I want to draw back a few steps and ask your indulgence to think through the issue with me in a more comprehensive way.

Let me start with a story. I have a friend named Tom Botts, who works with Royal Dutch Shell. Tom and his folks had put in place the world's most extensive safety program for people working on oil rigs. Much to his dismay, two workers went to the wrong part of a rig called Brent Bravo and did something totally contrary to all their safety training and were killed. It would be all too simple in a situation like that to blame the two workers for being inattentive to the safety rules, but Tom and his colleagues did something different. They engaged in what he called a "Deep Learning" exercise and discovered that the problem lay not in well-intentioned people who made mistakes, but in the leadership of the organization for failing to fully understand what it would take reduce the chance of errors.

Here's an example of one of his conclusions:

"A system full of well intended, competent people working world class systems trying their best to meet expectations can produce fatalities."
Probably the most profound learning for me. In the Brent Bravo story, there were no obvious ‘villains’, but rather a number of causal patterns that came together to produce a tragedy. The whole point of Deep Learning for each of my senior leaders and me was to be able to see ourselves in the system and what causal patterns we could have been able to break (if we had a better appreciation for the unintended consequences of our many well intended decisions). Key questions: Am I asking the right questions? Am I curious enough?

(If you would like, you can read other parts of the story and Tom's other lessons on my blog here.)

So, now let's go back to BIDMC. That there were flaws in our infection control procedures and techniques is quite evident from the DPH/CMS report. Let's not deny those. But let's also assume that the well-intentioned and highly trained people in our hospital were extremely unlikely to have made these errors intentionally. As one of our nurses said to me, "There is a difference between knowing what to do properly, and deciding not to do it despite knowing it." And then she said, "I truly believe we are the best hospital here in Boston. That is why I choose to work here. We are open with our mistakes, as that is how we are able to learn and progress. It hurts to see our name slandered, and our reputation diminished over this. Can we do better? Yes. And we are already. Our policies are being rewritten, and our procedures reviewed. This is an issue that is in EVERY hospital. Please don't let this disintegrate further into an atmosphere of fear and punishment. Please use this as a tool for internal review and reflection."

Although we have made a full and complete response to the DPH/CMS findings, we are in the business of continuous improvement here, and I want to see if we can do better still . . . with your help. In the past several weeks, we have seen the power of our joint action in adopting budget and personnel actions that reflect our deepest values of caring and compassion. Our town meetings and chat rooms and emails produced a result that solved a serious budget problem . . . and by the way, brought great national acclaim to our hospital.

I would like to try to do the same here. I don't think large-scale town meetings fit the bill for this exercise, and I also don't think the imprecision of chat rooms and emails would work in this case, either. Instead, over the next several weeks, I will convene a series of focused discussion groups with those of you who would like to join me and a small group of Chiefs and Vice Presidents. Your task will be simple and direct: Tell us what we don't know that we should know to help make it more likely that future quality and safety problems will be diminished. We'll then take what we learn from you and do our best to construct the training, procedures, and infrastructure that will move us along in this journey.

In the next few days, you will see an email setting forth a schedule for these meetings, and you will be able to sign up for one that is convenient for you. I welcome and treasure your participation.

Sincerely,

Paul

Just when you thought you were sure . . .

. . . that you knew everything there was to know about your family, you learn something. This is the Bridgeport (CT) Telegram from May 12, 1922, and it is about my grandmother. My sister, our family genealogist, found it somehow. It's hard to read, so here's the text:

Mrs. Rose Levy Bound Over on Bigamy Charge
Mrs. Rose Levy of Grove Street was arrested yesterday morning on a charge of bigamy. Believing her first husband Isaac Grannick of Philadelphia had died eight years ago she became the wife of I. Levy. Recently the first husband came to Bridgeport and confronted his wife threatening prosecution. She reported his threats to the authorities through her counsel and her arrest followed. In City Court yesterday morning she was bound over the the Superior Criminal court in $100 bonds.

Now, this was six years after my father was born, so I guess she was a bit surprised. We will probably never know if she really thought Isaac was dead or whether, in the tradition of certain Eastern European Jews, she just considered him dead for some injustice that he had done her.

Unfortunately, we have not yet found the sequel. Was she found guilty or innocent? I'm also not clear, though, what the penalty was back then for bigamy. How would you handle the existence of the son by the second marriage? Do you force a divorce on the first couple and then re-marry the second couple?

In the 20+ years I knew her while I was growing up, I never heard mention of this incident. What have you found in your family history that was news to you after years of ignorance? Please submit stories.

Retake that PK!

Our youth soccer leagues get started today on a blustery spring New England day, and a friend uses the occasion to send the following note to our cadre of adult referees:

I know some of the kids think we are "old farts" but this article from the BBC is interesting, especially on a "windy" day in Newton. Sunday League football in England is the equivalent of our Over The Hill Soccer League. Enjoy.

Dropping by NECN

Did you ever wonder who is in charge of the business news you read in Boston? Well, here they are. While I was waiting to tape an interview on This Week in Business at New England Cable News, the first segment of the show was being taped. It is called the "Monthly Business Editors' Roundtable." From left to right, you have the hosts of the show -- Paul Guzzi, CEO of the Greater Boston Chamber of Commerce, and Mike Nikitas, an NECN anchor -- and then Frank Quaratiello (Business Editor of the Boston Herald); Shirley Leung (Business Editor of the Boston Globe); and George Donnelly (Editor of the Boston Business Journal).

The topic today was the future of the Boston Globe, and it is a discussion worth hearing. My segment was about the steps BIDMC has taken to avoid layoffs in the face of budget shortfalls. The show will be broadcast on Sunday at 12:30. It is also available after broadcast on NECN.com and the Chamber's blog, too.

As I was leaving, I was nabbed by Latoyia Edwards, an NECN reporter and anchor, for a quick interview on our recent MRSA problem and DPH report. Here she is while a cut-away is being filmed.

Future leaders

I joined a group of Harvard undergraduates today at their class, "The Quality of Health Care in America," co-taught by several medical luminaries -- David Blumenthal, Don Berwick, and Warner Slack and Howard Hiatt (shown here). A great conversation ensued about transparency and process improvement. There were several pre-med students in the class. Perhaps this course will give them the impetus to focus on the quality of the health care delivery system when they become doctors.

A good birth!

A lovely letter about our staff from a new mother:

In Wikipedia, a nurse is defined as a healthcare professional focused on the detail-oriented care of individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. While that may be true by definition, my nurses at BIDMC for my stay with my new son Julian from March 26 to 28 were so much more than that.

My labor and delivery nurse was Cheryl Sirois. She was an extremely friendly and outgoing woman, and I knew right away that I was going to enjoy my delivery and have no worries. She never seemed distracted or left me alone for long periods of time. Her 9 years of labor and delivery experience showed when she spoke up on my behalf and informed the Anesthesia team that I would prefer not to have a student administer my epidural. I had had a bad experience with one of my other deliveries and even though I had agreed early on for a student to give me the medication (I was having a bad contraction at the time!) I had changed my mind, yet was to nervous to speak up. Cheryl said no worries and informed the team my wishes to have the chief resident administer the epidural/spinal tap. I am so grateful for Cheryl's advocacy. I had a great pain free birth.

I, as well as my newborn son, experienced superior care while staying in room 767. My recovery was difficult in the early hours as I experienced heavy bleeding and the passing of large clots over my first night. Bonnie Biederman was my overnight nurse during this alarming night. She was calm and collected, friendly and efficient. I was scared at the thought of having to have an internal to check for clots. She made me feel secure and was right there through it all as I squeezed her hand, then her elbow and then her whole entire arm! I was thankful to have an experienced nurse for my overnight care that night. She had a busy night with many other patients but always managed to check in and make sure I had all that I needed. I am very lucky to have had her during that traumatic time.

My next morning, I was even more blessed to have the care of Suzanne Sweeney. What a breath of fresh air she is and the perfect nurse to have after a horrible and scary evening before. She was kind and funny, always laughing and friendly. After having such a rough night, she was just what I needed! I happened to pass another large clot while she was on duty and became worried. She calmed my fears and said it was okay and there was no concern. She was always there to check in on my needs and would return with supplies and a smile. She mentioned more than once to me that she loves her job, and I believed her! This woman loves what she does and it shows.

Suzanne continued to care for me the following day. How lucky was I to have her two days in a row! She has a special gift with handling newborns. Watching her talk with my son Julian was heartwarming. He responded to her immediately. She has a terrific bedside manner and I wish everyone that comes through Beth Israel Deaconess for labor and delivery could experience even a sliver of Suzanne's care!

You are lucky to have these professional women on your team. Please know that their care was exceptional. As stated above, a nurse is defined as a professional focused on the detail-oriented care of individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. While these women certainly fulfill this definition, they all went above and beyond their job requirements and made my stay at Beth Israel Deaconess comfortable, fun, reassuring and stress-free.

Thank you, Beth Israel Deaconess, for hiring such a top notch team!

DPH and CMS help out

While we are justly proud of many of our quality and safety initiatives at BIDMC, we have to acknowledge that we still fall short in a number of ways. The memo below, distributed to our staff yesterday, contains an example.

Just as we view transparency around our clinical outcomes as an important management tool, we view transparency about regulatory activities, findings, and requirements in the same way. If a regulatory agency finds that we are doing things wrong, why would you want to keep that conclusion secret from the staff? After all, the doctors, nurses, and others are the ones who ultimately must correct the problem, and we trust their ability to evaluate and act on legitimate criticisms received by us.

In a previous post about the Joint Commission, I stated: "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." Ditto for our state and federal regulators.

Here's the memo:

To: BIDMC Community

From: Ken Sands, MD
Senior Vice President,
Silverman Institute for Health Care Quality and Safety

DeWayne Pursley, MD, MPH
Neonatologist-in-Chief
Interim Chief, Obstetrics and Gynecology

Marsha Maurer
Vice President, Patient Care Services
Chief Nursing Officer

We are writing to share important information about some serious clinically related issues at BIDMC over the past few months. To begin, we will give you some background, and then we will fill you in on what happens next.

What Has Occurred
First, between last November and March, BIDMC experienced several occurrences or “clusters” of methicillin-resistant Staphylococcus aureus, or MRSA, infections that have affected some of our patients (19 newborns and 18 mothers) days to weeks after discharge from our obstetrics and newborn services. These infections have been, for the most part, superficial skin infections and breast infections. It is important to note that no babies in our Neonatal Intensive Care Unit have been affected.

We are thankful that all identified infections have been successfully treated, in most cases with antibiotic cream or pills. We are working to identify any other patients who may have been affected. It appears that these clusters of infection have not impacted other parts of the hospital.

As with other hospitals and institutions that have experienced similar groups of MRSA infection, it is often impossible to identify a singular source or explanation. We have determined the bacteria to be the most common type of “community-associated” MRSA, meaning that the origin of the bacteria is most likely outside BIDMC. Despite extensive investigation, we have been unable to determine how it has spread. However, we have taken many steps within our obstetrics and newborn services to address this situation, including testing our employees and patients and strengthening our efforts on hand hygiene and sterilization.

We promptly reported these occurrences to the Massachusetts Department of Public Health (DPH) and the Boston Public Health Commission (BPHC) and continue to work closely with them. In addition, to help us with this ongoing challenge, we are working with the national Centers for Disease Control and Prevention (CDC), and we welcome their expertise and knowledge of similar situations. Our outreach has included communications with affected patients, patients who we believe have not been affected but were here at the same time as the affected patients, pediatricians and current patients in our obstetric units.

Second, during the course of a DPH visit regarding the MRSA matter on behalf of the federal Centers for Medicare and Medicaid Services (CMS), investigators observed instances when our infection control practices failed to meet our own standards. In addition, they had concerns about our system for reporting infection clusters to leadership bodies within the hospital.

What Happens Next
We have received the official CMS report and are putting together what is called a Plan of Correction to show how we will correct any and all deficiencies that were identified. We will make both their full report and our response available to the BIDMC community when they are filed within a couple of days. But as a result of the findings, a more vigorous, hospital wide survey by CMS will be coming to BIDMC in the near future for their own review and inspection of our policies and procedures. Every physician and employee must be prepared to welcome the CMS surveyors and show them the good work that we know BIDMC staff are doing every day.

Some Observations
We take the report on our lapses and the expected CMS visit very seriously. When we make this report available to all, you may find reading the report makes you uncomfortable. It is difficult for a group of expert and dedicated staff like our colleagues in Obstetrics and Newborn services to go through this process. They have worked extremely hard over the past few months to battle these MRSA infections and to re-dedicate themselves to the most rigorous infection control processes.

Yet the truth is any one of us at any time could be subjected to the same scrutiny and observation and we each need to ask ourselves how we would fare in this situation. This is an important learning experience for every one of us as we deal with the patients and family members who put their trust in us.

There is much to be proud of at BIDMC with our efforts to control infections. We have virtually eliminated central line infections and ventilator associated pneumonia over the past few years by implementing and standardizing major new processes. Each year, the outstanding clinicians at BIDMC provide quality care with exceptional outcomes to tens of thousands of patients.

The serious nature of the initial survey does not change those facts. But it does require that we continue to commit ourselves to providing the highest quality care to every patient who counts on us for their health care needs. Ultimately we believe the changes we will put in place as a result of this experience will make us stronger and better caregivers.

Reprise: St. Thomas Charoset

A repeat of my grandmother's recipe for charoset, that sweet stuff we eat at Passover. Enjoy!

In memoriam: Doctor Harvey Goldman

It was somehow appropriate that Harvey Goldman died yesterday, in that it was to have been Opening Day for the Boston Red Sox. It felt even more appropriate that the game was postponed, though, for it would not have seemed right for it to have taken place without him.

Harvey was an avid fan who went to most games. He sat in the family section at Fenway Park, down the left field line in the outfield, where alcoholic beverages are prohibited. He told me that there he could have relative peace and quiet during the games and not have to worry about someone spilling beer over him. As I sat through the rescheduled game today, I often thought of him because the view from my seat looks directly across to where he used to sit. He would bring books and academic journals with him to the game, to read during the inning breaks, so as not to waste time.

My favorite memory of Harvey, though, was two or three days after I had a routine colonoscopy, when two or three polyps had been snipped off. We happened to meet on Longwood Avenue as we walked toward the hospital. "Good morning," I said, "How are you?" "Fine," he replied, "and so are you. I did the histology on your samples yesterday."

As noted by our Chief of Pathology, Jeffrey Saffitz, "Harvey was a giant in the field of gastrointestinal pathology and a true icon in our department and in the Harvard pathology community. His dedication to teaching and patient care was legendary. He touched the lives of literally thousands of medical students, residents, fellows and colleagues in so many wonderful ways. He will be greatly missed."

Doctors' Diaries on NOVA

NOVA Producer Paula Apsell at Boston's WGBH reminds me (and now you!) of the following:

I am writing to alert you to a special NOVA two-hour miniseries to be shown on WGBH Channel 2 at 8 PM on Tuesday, April 7th and the following Tuesday April 14th.

For the past 21 years, NOVA has been following a group of 7 aspiring young doctors from their first day at Harvard Medical School through internship, residency and out into the world as practicing physicians. The resulting documentary, called Doctors' Diaries, reveals in illuminating detail the joys and sorrows, sacrifices and rewards that go into becoming a member of the medical tribe. I think these programs might be of special interest to you and I hope you will be sure to tune in or set your DVR.

Check local times for your own PBS station.

Blog Rally to help the Boston Globe

We have all read recently about the threat of possible closure faced by the Boston Globe. A number of Boston-based bloggers who care about the continued existence of the Globe have banded together in conducting a blog rally. We are simultaneously posting this paragraph to solicit your ideas of steps the Globe could take to improve its financial picture:

We view the Globe as an important community resource, and we think that lots of people in the region agree and might have creative ideas that might help in this situation. So, here's your chance. Please don't write with nasty comments and sarcasm: Use this forum for thoughtful and interesting steps you would recommend to the management that would improve readership, enhance the Globe's community presence, and make money. Who knows, someone here might come up with an idea that will work, or at least help. Thank you.

(P.S. If you have a blog, please feel free to reprint this item and post it. Likewise, if you have a Twitter or Facebook account, please add this url as an update or to your status bar to help us reach more people.)

Doing "a Beth Israel"

A friend at another non-profit in Boston related this story. The organization faces severe budgetary problems. At a small meeting of some staff someone said, "Why don't we do 'a Beth Israel'?"

And another friend at a for-profit company related this story. "We have already implemented 'a Beth Israel' and saved 15% of our staff losing their jobs."

Have we become a neologism? (Addendum in response to comments: If so, can we change the expression to "Doing a Beth Israel Deaconess?")

Arlo Guthrie would say:

And three people do it, three, can you imagine ...
they may think it's an organization.
And can you, can you imagine fifty people ...
and friends they may thinks it's a movement.

Write back!

We all send emails and most of us have figured out how to affix a "signature" to the bottom of them. It automatically gives our name, title, and such. Mine has this blog address, my Facebook page, and my Twitter page. Some people post meaningful or funny quotes from famous people.

But this is the best signature I have seen. It is from Shira, a young friend on the soccer team I coach. I hope you like it, too.

Cleats not for sale

Twice a year, my friend Ed (Honora's dad) and I run a cleat exchange for our town's girls soccer league. This started because we noticed that little kids outgrow their athletic footwear before they wear it out, and we figured it could be recycled to the next generation. This is a pretty simple event. We put out tables and ask people to drop off or bring the outgrown cleats. People who need new ones then come by and take what they need. No muss, no fuss, no money.

Meanwhile, Ed and I pretend to be shoe salesmen. We gently persuade 8 year-old girls that the eighth or tenth pair they have tried on -- the pair of cleats that finally fits them -- are really special because they have a purple stripe or some other design feature. They always fall for it, and the parents are amazed at our "sales" ability.

About 200 families find a free pair of shoes in a three-hour period. Ed and I get to meet the new generation of soccer stars, and there is a warm and communal feeling to the whole thing. We have been doing this for so many years that we have lost track of how many. I decided to memorialize the event here and include pictures of some of this morning's customers.

Reach out and open up, Globe!

There is a very, very disturbing story in today's Boston Globe about the Globe itself. The NY Times company, which owns the paper, is demanding major concessions from the unions and is threatening to close the paper if it does not receive them. The thought of losing this newspaper is deeply disturbing. It is the major source for investigative journalism that keeps the government, corporations, and, yes, non-profits honest and accountable. We simply cannot afford not to have it.

Yet, I look at these two lines from the story and experience cognitive dissonance.

Catherine Mathis, a Times Co. spokeswoman, declined to comment last night. Globe publisher P. Steven Ainsley also declined to comment.

The Times Co. is seeking concessions from the unions because the New York company, which is also suffering from the recession, can no longer subsidize the Globe's losses, said the Globe employee who is not authorized to speak publicly and requested anonymity.

The entire story is splayed across the front page and yet company people will not comment or they seek anonymity. What is there left to be held confidential? If you are seeking concessions from the staff, you need to be totally transparent with regard to the situation so you can be trusted in providing accurate financial information. Maybe a union environment makes this harder to do, but it is not impossible.

Also, why isn't the Globe asking their biggest natural constituency -- the loyal readership -- for ideas and suggestions that might help in some ways to save the paper?

Back in 2007, I wrote about the newspaper and made some suggestions along these lines. Maybe they were good ideas or maybe they were stupid, but the point is that there are a lot of engaged and thoughtful people in the region who would want to help. My conclusion still holds:

If people believe it is their paper they will read it. Use the forces and opportunities of technology to make it happen so your excellent reporters and columnists can earn a salary and work on the really important functions envisioned in the Constitution.

Paul Solman on PBS tells the BIDMC story

Paul Solman, on PBS' Newshour with Jim Lehrer, provided a view tonight of recent activities at a musical instrument company in Elkhart, Indiana, and at BIDMC, emphasizing the participation by a wide range of staff members in efforts to avoid layoffs and protect lower wage workers. Here's a more detailed discussion on Paul's Business Desk site.

Those of you following this blog have seen lots of details on this already, but I thought you would be interested in a few aspects of that participation.

After I sent out my first budget message and held town meetings with what must have been 2000 employees, I received about 2700 suggestions and comments in form of direct emails, Facebook messages, and comments on the chat room we had set up. (For context, remember that we have about 6400 full-time equivalent employees and about 800 doctors who work here.)

After I sent out the second message, outlining ideas that I was tentatively thinking of adopting, I received another 800 messages and chat room suggestions. And, after I sent out the final message with our detailed budget plan, I received about 100 comments.

I do not yet have the final numbers of how many generous doctors and other staff have sent in donations, but it is already several dozen, offering tens of thousands of dollars in gifts to save more jobs.

Peter Alexander tells BIDMC's and Rebecca's story

I recently had a chance to meet Peter Alexander, from NBC News. He filmed the following segment about our hospital, which was broadcast tonight. You see him above visiting some of the nurses in our NICU.

Visit msnbc.com for Breaking News, World News, and News about the Economy

But, here's an even more impressive story done by Peter about his sister, who is losing both her sight and her hearing as a result of a rare neurological disorder.

Residents learn LEAN, too

Part of BIDMC SPIRIT is to infuse many of the LEAN process improvement principles throughout the hospital. A key constituency in this effort are the residents who, after all, spend as much time on the patient care floors as anybody. So, we have begun a training program for this group, and the first sessions were held this week.

Shown here is Alice Lee, our LEAN guru, er, sensei, conducting a class. Also, you see a couple of the students on the floors, quietly observing things and learning how to look for waste and opportunities for efficiency improvements.

MHQP goes for five in a row

A note from Barbra Rabson, which I am happy to pass along:

Massachusetts Health Quality Partners (MHQP) today released the organization's fifth annual Quality Insights: Clinical Quality in Primary Care report, comparing the performance of 150 medical groups across the state. The results are available here, where consumers can compare how well medical groups perform in meeting national standards for providing preventive care, helping patients manage chronic conditions such as diabetes, and avoiding the overuse of certain medications and tests. MHQP was recently chosen by the Massachusetts Health Care Quality and Cost Council to develop a three-year plan for the public reporting of comparative health care quality and cost information for the Commonwealth.

Celebrating quality and safety at work

Three years ago, our Board Chair, Lois Silverman, and her late husband, Norman, established the Silverman Institute for Healthcare Quality and Safety. It was to serve as the focal point for research, teaching, and implementation of improvements in patient and staff quality and safety for our hospital.

A symposium is held each year, with a speaker of national renown in the field. Last year, it was Brent James, from Intermountain Health. This year, we were pleased to welcome MIT's Steven Spear.

The symposium is also accompanied by a poster session at which staff members report on achievements in the six dimensions of care defined by the Institute of Medicine: Safe, Effective, Timely, Efficient, Patient Centered, and Equitable. We received over 90 such submissions this year and held the poster session in the lobby of our clinical center. You can read about all of them here. The pictures here show some of the proud presenters.