My end-of-term visits at various of the city's colleges and universities continued tonight with a session at MIT's Baker House dormitory, meeting with Housemasters Dava Newman and Gui Trotti and the Baker House Leaders. The topic was how to introduce quality and safety process improvement in hospitals, and the role of transparency in establishing creative tension in an organization in the drive to eliminate preventable harm. With their background in aerospace engineering and design, Dava and Gui were superb hosts for the event. The students, who organized the evening, made excellent observations about the symptoms and causes of harm in the hospital environment.
Wednesday, May 4, 2011
Baker House leads
My end-of-term visits at various of the city's colleges and universities continued tonight with a session at MIT's Baker House dormitory, meeting with Housemasters Dava Newman and Gui Trotti and the Baker House Leaders. The topic was how to introduce quality and safety process improvement in hospitals, and the role of transparency in establishing creative tension in an organization in the drive to eliminate preventable harm. With their background in aerospace engineering and design, Dava and Gui were superb hosts for the event. The students, who organized the evening, made excellent observations about the symptoms and causes of harm in the hospital environment.
Maureen on WIHI
Leading Across the Continuum
Thursday, May 5, 2011, 2:00 PM – 3:00 PM Eastern Time
Thursday, May 5, 2011, 2:00 PM – 3:00 PM Eastern Time
Guest: Maureen Bisognano, President and CEO, Institute for Healthcare Improvement
If you want to lead across the continuum, you have to care across the continuum. And not just at the moment when patients happen to be in your hospital beds, or are sitting in your office practice, or are on the phone. Clinical and administrative leaders now have to also care about what they either don’t see or have learned to ignore, or assume someone else is dealing with in some other health care setting. Patients and family members usually have the complete story, if anyone bothers to listen. The challenge now is to build the system that can engage with the patient/family narrative and put it to good use.
IHI President and CEO Maureen Bisognano can’t think of anything more important than reforming health care in the US and elsewhere so it’s better integrated, better coordinated, and much, much more cost effective – across the continuum. However, what sometimes sets her apart from the rhetoric “du jour” is that she’s relentless about anchoring changes in the patient’s journey. That can sound easy, but it isn’t – even when the handwriting is on the wall with bundled or global payments, patient-centered medical homes, accountable care organizations (ACOs) and more – all of which, by definition, require much greater awareness of the patient experience. Leaders tend to get caught up in contractual and legal issues, certifications, revenue sharing, and what’s next with public reporting.
The good news is that Maureen views the current state as an opportunity, not a barrier, and she’s criss-crossing the country talking with frontline caregivers and leaders alike about the tremendous opportunity everyone now has to innovate and build new models of care with patients at the center. Over and over again, Maureen will say there is a connection between what patients know and what clinicians know – and when the information becomes part of a shared pool of knowledge, amazing things happen. And, she’s gathering the evidence to prove it.
WIHI host Madge Kaplan is pleased to welcome Maureen Bisognano to the program, fresh off her recognition by Modern Healthcare as one of the Top 25 Women in Healthcare for 2011. Please join us!
To enroll, please click here.
HHS recognizes top performers
Speaking of best practices, check out this announcement from the US Department of Health and Human Services.
The U.S. Department of Health and Human Services today recognized 37 hospital and healthcare facilities for their efforts to prevent – and eventually eliminate – healthcare-associated infections (HAIs), a leading cause of death in the United States.
The U.S. Department of Health and Human Services today recognized 37 hospital and healthcare facilities for their efforts to prevent – and eventually eliminate – healthcare-associated infections (HAIs), a leading cause of death in the United States.
HAIs are infections that are acquired while patients are receiving medical treatment for other conditions. At any given time, about 1 in every 20 patients has an infection related to their hospital care. These infections cost the U.S. healthcare system billions of dollars each year and lead to the loss of tens of thousands of lives. In addition, healthcare-associated infections can have devastating emotional, financial and medical consequences.
“People enter a hospital expecting to get healthier, not sicker,” said Assistant Secretary for Health, Howard K. Koh, MD, MPH. “We applaud hospitals for their efforts in improving the quality and safety of healthcare for all Americans.”
The organizations are the first to be honored as part of a new national awards program to highlight successful and sustained efforts to prevent healthcare-associated infections, specifically infections in critical care settings. This initial set of awards recognizes critical care professionals and healthcare institutions for their efforts to reduce, and eventually eliminate, ventilator-associated pneumonia and bloodstream infections associated with central intravenous lines.
HHS partnered with the Critical Care Societies Collaborative (CCSC) to develop the awards program. CCSC is a multidisciplinary organization that promotes the exchange of ideas about critical care practice and ICU patient care among leaders from medicine, nursing, pharmacy and respiratory therapy.
Ten recipients were recognized today during the American Association of Critical-Care Nurses’ (AACN) National Teaching Institute & Critical Care Exposition in Chicago. The remaining 27 recipients will be recognized throughout the year at the conferences of CCSC member societies.
Awards were conferred on two levels, according to specific criteria tied to national standards. The “Outstanding Leadership Award” went to teams and organizations that sustained success in reaching their targets for 25 months or more. The “Sustained Improvement Award” recognizes teams that demonstrated consistent and sustained progress over an 18- to 24-month period.
Initial award recipients are:
Achievements in Eliminating Ventilator-Associated Pneumonia and Central Line-Associated Bloodstream Infections
Outstanding Leadership Award
- St. Joseph Mercy Hospital, Ann Arbor, Mich.
- Mercy Hospital ICU, St. Paul, Minn.
- North Shore-LIJ Health System, New York, N.Y.
- Riverside Methodist Hospital, Columbus, Ohio
Sustained Improvement Award
- Beth Israel Deaconess Medical Center, Boston, Mass.
- Detroit Medical Center, Detroit, Mich.
- Lakeland HealthCare, St. Joseph, Mich.
- Norman Regional Health System, Norman, Okla.
- Salem Health Critical Care Services, Salem, Ore.
- Baptist Memorial Hospital-Memphis, Memphis, Tenn.
Achievements in Eliminating Central Line-Associated Bloodstream Infections
Outstanding Leadership Award
- Yale-New Haven Children’s Hospital Newborn Special Care Unit, New Haven, Conn.
- HealthPark Medical Center Open Heart ICU, Ft. Myers, Fla.
- University of Michigan Hospitals & Health Centers Critical Care Medicine Unit, Ann Arbor, Mich.
- Children’s Hospital & Clinics of Minnesota, Minneapolis, Minn.
- Stony Brook University Medical Center, East Setauket, N.Y.
- Rome Memorial Hospital, Rome, N.Y.
- Lehigh Valley Health Network, Allentown, Penn.
- Cook Children’s Medical Center, Fort Worth, Texas
Sustained Improvement Award
- Children’s National Medical Center, Washington, D.C.
- Howard County General Hospital, Baltimore, Md.
- Rochester General Hospital, Rochester, N.Y.
- Akron Children’s Hospital NICU, Akron, Ohio
- Cleveland Clinic Cardiovascular ICU, Cleveland, Ohio
- Medina Hospital ICU, Medina, Ohio
Achievements in Eliminating Ventilator-Associated Pneumonia
Outstanding Leadership Award
- Seton Medical Center, Daly City, Calif.
- University Hospital, Augusta, Ga.
- St. Catherine of Siena Medical Center, New York, N.Y.
- Johnson City Medical Center, Johnson City, Tenn.
- Baylor University Medical Center Truett ICU, Dallas, Texas
- St. Luke’s Episcopal Hospital, Houston, Texas
Sustained Improvement Award
- St. Joseph Hospital Orange, Orange, Calif.
- Huntington Memorial Hospital, Pasadena, Calif.
- Palmdale Regional Medical Center, Palmdale, Calif.
- Saint Anne’s Hospital, Fall River, Mass.
- Carolinas Medical Center NeuroSurgical ICU, Charlotte, N.C.
- Highland Hospital ICU, Rochester, N.Y.
- Providence St. Mary Medical Center, Walla Walla, Wash.
Last month, HHS launched the Partnership for Patients, a new national partnership with hospitals, medical groups, consumer groups and employers that will help save lives by preventing millions of injuries and complications in patient care over the next three years. HHS has set a goal of decreasing preventable hospital-acquired conditions by 40 percent (compared with 2010 rates) by the end of 2013. Achieving this goal should result in approximately 1.8 million fewer injuries and illnesses to patients, with more than 60,000 lives saved over the next three years. The Partnership for Patients has the potential to save up to $35 billion across the healthcare system, including up to $10 billion in Medicare savings over the next three years.
For additional information, see the HHS Action Plan to Prevent Healthcare-Associated Infections and the Partnership for Patients.
Tuesday, May 3, 2011
Use that hammer on a real nail, Don
Although I spent nine years running a hospital, and over twenty years before that in the public policy realm, I still don't understand how policy is made in the health care field. Look at this article from Kaiser Health News about a new approach to Medicare payments:
Medicare took its broadest step yet in moving away from its traditional hospital payment method, finalizing a plan to alter reimbursements based on the quality of care hospitals provide and patients’ satisfaction during their stays.
The initiative is the beginning of a transition from paying hospitals on the basis of the amount of care they provide. Many health care researchers believe this fee-for-service system has encouraged unnecessary care, driving up costs and giving hospitals no incentive to economize.
Let's stop right there. Notice how we are talking about a transition from fee-to-service to some kind of capitated or bundled payment approach. As I have mentioned before, even in way-ahead Massachusetts, no one has produced data to test whether the latter approach makes any difference.
But maybe the reporter was just concatenating two unrelated topics. Here's the actual program:
Under the final rules announced Friday, Medicare will cut payments to hospitals 1 percent and set that money aside for a bonus pool. Hospitals that do better than average on a variety of measurements, or show the greatest improvement from the previous year, would earn bonus payments, totaling $850 million in the first year. The bonus pool would increase to 2 percent of Medicare payments in October 2016.
Here we go again. When you have a hammer, everything looks like a nail.
Is Medicare adopting this approach as a movement away from fee-for-service (as the reporter suggests), or is it simply an approach meant to encourage better quality? If the latter, is it the right approach? Are the dollars significant enough? Are the dollars paid to a hospital a persuasive way to encourage nurses and doctors to do things differently?
I don't know of any hospital administrator who has been successful in motivating doctors and nurses to engage in process improvements by stressing possible impacts on the hospital's bottom line. Indeed, most doctors I have talked to have said that this is the quickest way for them to become uninterested.
Look, doctors and nurses have devoted their lives to alleviating human suffering caused by disease. What is motivational are changes that permit that to be done better. The good news is that improvements in quality and safety also help reduce costs and thereby improve a hospital's bottom line. Captain Sullenberger, Brent James, Lucien Leape, and Spear-Toussaint-Kaplan and others have set forth a very clear agenda as to how to make that possible.
One factor that is missing today, though, is the ability of doctors and nurses to share best practices and learn from their colleagues in other hospitals. But the Joint Commission, which collects these best practices while charging accreditation fees to the hospitals that provide these stories, keeps this information in a locked-up library.
Open note to Dr. Berwick at CMS:
"The Joint Commission has been delegated its powers by your agency. You have given it a license to collect fees from the public. Isn't it time for you to write or call that agency and demand that the Leading Practice Library it has assembled using those fees be made widely available -- to all people in hospitals, and indeed to the public at large?
"You have this hammer, too. Why not pound on a nail that is clearly sticking up?"
Medicare took its broadest step yet in moving away from its traditional hospital payment method, finalizing a plan to alter reimbursements based on the quality of care hospitals provide and patients’ satisfaction during their stays.
The initiative is the beginning of a transition from paying hospitals on the basis of the amount of care they provide. Many health care researchers believe this fee-for-service system has encouraged unnecessary care, driving up costs and giving hospitals no incentive to economize.
Let's stop right there. Notice how we are talking about a transition from fee-to-service to some kind of capitated or bundled payment approach. As I have mentioned before, even in way-ahead Massachusetts, no one has produced data to test whether the latter approach makes any difference.
But maybe the reporter was just concatenating two unrelated topics. Here's the actual program:
Under the final rules announced Friday, Medicare will cut payments to hospitals 1 percent and set that money aside for a bonus pool. Hospitals that do better than average on a variety of measurements, or show the greatest improvement from the previous year, would earn bonus payments, totaling $850 million in the first year. The bonus pool would increase to 2 percent of Medicare payments in October 2016.
Here we go again. When you have a hammer, everything looks like a nail.
Is Medicare adopting this approach as a movement away from fee-for-service (as the reporter suggests), or is it simply an approach meant to encourage better quality? If the latter, is it the right approach? Are the dollars significant enough? Are the dollars paid to a hospital a persuasive way to encourage nurses and doctors to do things differently?
I don't know of any hospital administrator who has been successful in motivating doctors and nurses to engage in process improvements by stressing possible impacts on the hospital's bottom line. Indeed, most doctors I have talked to have said that this is the quickest way for them to become uninterested.
Look, doctors and nurses have devoted their lives to alleviating human suffering caused by disease. What is motivational are changes that permit that to be done better. The good news is that improvements in quality and safety also help reduce costs and thereby improve a hospital's bottom line. Captain Sullenberger, Brent James, Lucien Leape, and Spear-Toussaint-Kaplan and others have set forth a very clear agenda as to how to make that possible.
One factor that is missing today, though, is the ability of doctors and nurses to share best practices and learn from their colleagues in other hospitals. But the Joint Commission, which collects these best practices while charging accreditation fees to the hospitals that provide these stories, keeps this information in a locked-up library.
Open note to Dr. Berwick at CMS:
"The Joint Commission has been delegated its powers by your agency. You have given it a license to collect fees from the public. Isn't it time for you to write or call that agency and demand that the Leading Practice Library it has assembled using those fees be made widely available -- to all people in hospitals, and indeed to the public at large?
"You have this hammer, too. Why not pound on a nail that is clearly sticking up?"
Monday, May 2, 2011
Mad about Marty
It is a wonderful thing when members of the community join together to recognize a person who has contributed to the fabric of life in a city, and many of us did so tonight. The occasion was the retirement celebration for Martha ("Marty") Jones, who is leaving her post next month as head of the Celebrity Series of Boston after 25 years of service. Entitled Mad about Marty, the evening comprised a concert of visiting artists and a dinner.The Celebrity Series is a non-profit organization that brings performing artists from around the world to perform in Boston. It also supports arts education programs like Ailey Camp for children in the city. I have been fortunate to be on the Board of Trustees since 2004.
I am able to offer only these rather impressionistic photos from my old cell phone, as I was trying to catch images in a dark theatre from a distance. Among those artists on hand tonight who donated their time and talent to pay tribute to Marty were a trio of David Finckel (cello) and Philip Setzer (violin) -- one half of the Emerson Quartet -- and Wu Han (piano), who played parts of the Schubert Piano Trio in B-flat Major, Opus 99.
Wu Man also showed up, playing the pipa. Sometimes called the Chinese lute, the instrument has four strings attached to a pear-shaped wooden body, with a varying number (12-26) of frets. I include a video below to give you a sense of the sound of this instrument and a sample of Wu Man's skill and talent. If you cannot see the video, click here.Wisconsin CEO blogger
A Wisconsin hospital CEO joined the list of the few who write blogs. This is Dave Dobosenski, CEO of St. Croix Regional Medical Center. The blog is entitled Small Hospital - Big Heart. I've linked to it on the right below. It looks like he started a couple of months ago. His purpose:To educate the on-line community about St. Croix Regional Medical Center, an independent, not-for-profit, integrated delivery system with 4 community locations. It is an opportunity to dialogue about health care topics, promote organization and community events, and share personal experiences.
Dave provides a welcome perspective from Wisconsin and from a number of small health care facilities. Let him know you appreciate his contributions.
Sunday, May 1, 2011
I wish we were less patient
The sad case of Kimberly Hiatt, a Seattle nurse who committed suicide months after being disciplined for administering a fatal dose to an infant, is starting to make the rounds. Josephine Ensign, for example, concludes her blog post on this by saying:
I am left with many questions. Why was the nurse treated so differently from the dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes . . . what do I teach my students to do?
We can never know, of course, whether the suicide was related to the incident itself, the disciplinary action, or indeed, some other aspect of Hiatt's life. But the sequence of events will cause many to draw the connection between the way Hiatt was treated after the accident and her death. In any event, though, the ambiguity as to whether or not it was connected does not take away from the kinds of questions raised by Ensign.
Captain Sullenberger raised this issue during his talk at MIT this past week. Citing this particular disciplinary case, he noted that the kind of approach taken was "not particularly helpful" in creating an environment in which crew resource management would be effectively implemented.
My regular readers know that my former hospital faced a similar issue following a wrong-side surgery. Would we punish the surgeon and others involved in the case? We decided not to, not because they had suffered enough themselves from the error, but because we felt that a "just culture" approach to the issue would suggest that further punishment would not be helpful to our overall goal of encouraging reports of errors and near misses. The head of our faculty practice put it well:
If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if these staff members are not punished than if they are.
Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job. As Tom Botts from Royal Dutch Shell commented about deaths on one of his company's oil rigs:
It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.
It also would have diminished the likelihood of widespread interdisciplinary participation in redesigning the work flow in our ORs. By making clear that the error was, in great measure, a result of systemic problems, all felt a responsibility to be engaged in helping to design the solution.
For over two-and-a half years, the IHI Open School has been using our approach to this case as a teaching tool, simply asking: "What do you think of the way the hospital responded to the error? What should happen next?"
There are now 123 pages of comments on the Open School website, and every day my email forwards several new ones to me. It is clear that this kind of issue raises strong feelings, and it is healthy for the debate to proceed. It may be that there cannot be universally applied principles, that each case is sui generis. But, even if we can get each hospital to consider the question -- before applying punishment -- If our goal is to reduce the likelihood of this kind of error in the future, what is the best course of action? -- then progress will have been made.
Still, I cannot think of Nurse Hiatt without crying, for her, her loved ones, the baby, and the baby's loved ones. Sully said it well, ""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."
I am left with many questions. Why was the nurse treated so differently from the dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes . . . what do I teach my students to do?
We can never know, of course, whether the suicide was related to the incident itself, the disciplinary action, or indeed, some other aspect of Hiatt's life. But the sequence of events will cause many to draw the connection between the way Hiatt was treated after the accident and her death. In any event, though, the ambiguity as to whether or not it was connected does not take away from the kinds of questions raised by Ensign.
Captain Sullenberger raised this issue during his talk at MIT this past week. Citing this particular disciplinary case, he noted that the kind of approach taken was "not particularly helpful" in creating an environment in which crew resource management would be effectively implemented.
My regular readers know that my former hospital faced a similar issue following a wrong-side surgery. Would we punish the surgeon and others involved in the case? We decided not to, not because they had suffered enough themselves from the error, but because we felt that a "just culture" approach to the issue would suggest that further punishment would not be helpful to our overall goal of encouraging reports of errors and near misses. The head of our faculty practice put it well:
If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if these staff members are not punished than if they are.
Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job. As Tom Botts from Royal Dutch Shell commented about deaths on one of his company's oil rigs:
It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.
It also would have diminished the likelihood of widespread interdisciplinary participation in redesigning the work flow in our ORs. By making clear that the error was, in great measure, a result of systemic problems, all felt a responsibility to be engaged in helping to design the solution.
For over two-and-a half years, the IHI Open School has been using our approach to this case as a teaching tool, simply asking: "What do you think of the way the hospital responded to the error? What should happen next?"
There are now 123 pages of comments on the Open School website, and every day my email forwards several new ones to me. It is clear that this kind of issue raises strong feelings, and it is healthy for the debate to proceed. It may be that there cannot be universally applied principles, that each case is sui generis. But, even if we can get each hospital to consider the question -- before applying punishment -- If our goal is to reduce the likelihood of this kind of error in the future, what is the best course of action? -- then progress will have been made.
Still, I cannot think of Nurse Hiatt without crying, for her, her loved ones, the baby, and the baby's loved ones. Sully said it well, ""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."
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